Karen Kayekjian
Bixby Program
Summer 2008
Armenia
Context of Armenia
As a post-Soviet Union Caucasus country, Armenia can be considered young and in continuous transition
politically and economically. It lies south of Russia, west of Azerbaijan, north of Iran and east of Georgia
and Turkey and its population seems to be around three million. Since the recent controversial election of
the president that triggered a rioting uproar in Republic Square, one can feel the deep tension that lies in
the hearts of many who disapprove of his supposed unlawful past. Despite the opposition that has
manifested into photographs of prisoners blanketing store windows and the rows of men, women and
children sleeping on the steps of Northern Avenue, the new government has gained the hopeful support of
many who believe that the most recent progressive step taken foreshadows a positive future for Armenia’s
healthcare system. On July 1st, the Ministry of Health (MOH) declared all deliveries and all associated
costs to be free of charge and it was made public with USAID funded posters on walls of hospitals,
polyclinics, medical ambulatories and health posts, television appearances of the MOH signing the decree
and radio advertisements. Although introduced in 1996 for mothers, women and children, the associated
Basic Benefits Package that also includes Pap smears, family planning consultations, prenatal care,
contraception provision, and pubertal-reproductive examinations for adolescent girls is still not entirely
covered by the government’s budget. In 2002, the Law on Reproductive Health and Abortion Rights was
passed indicating that all abortions within 12 weeks of gestation are permitted and legal, an abortion after
12 weeks is legal only in the case where the mother’s well-being is in danger or the mother makes the
choice based on social factors and that after an abortion, a woman receives appropriate consultation
including family planning methods. The last privilege of the law is not recognized or followed in all cases
of abortion. Primary and secondary healthcare were introduced in regions outside of Yerevan in 1996 and
for the entire country declared free of charge in 2006. Unfortunately, the scarcity of the government
health budget cannot support these changes in addition to paying for physician salaries; this dire situation
clearly explains the country’s well-established informal payment system. In 1997, in order to further
Karen Kayekjian
Bixby Program
Summer 2008
Armenia
support healthcare in rural areas, the World Bank and USAID created a curriculum to train doctors in
family medicine. Currently, each village of Armenia has a health post where a trained nurse offers
medical consultation, makes home visits and offers referrals to specialists in town hospitals, polyclinics or
medical ambulatories. In terms of family planning, consultation centers with a sufficient supply of
methods were established with the financial support of the United Nations Population Fund (UNFPA),
however today, many hospitals lack the appropriate stock of oral contraceptives, IUDs and condoms.
Instead, pharmacies have become a more reliable source and provider of methods for clients. More over,
in 2004, USAID, Emerging Markets and Save the Children, initiated ProjectNOVA, a five year program
to assess reproductive health in regions outside of Yerevan, to train ob/gyns, family doctors, midwives
and nurses in family planning consultation and create and distribute informational booklets regarding FP
methods, prenatal care, and postnatal care, as well as train nurses, feldshers and midwives in safe
motherhood skills training.
Activities
As a Bixby intern in Armenia, my objective was to gain a better understanding of the context of
reproductive health in the country in terms of policies and laws, relevant programs, projects and
organizations, and the perceptions and practices of married men and women, mother in laws and ob/gyns.
A thorough policy review revealed all the above-mentioned laws and policy changes that have occurred in
Armenia within the past five to ten years. Furthermore, an extensive literature review showed studies that
thus far have used a survey, focus group, intervention and assessment approach to investigate the use of
modern contraception as well as the current situation of reproductive health services in rural and urban
Armenia. A lack of open-ended questions and the use of focus groups instead of individual interviews in
these studies may have hindered candid responses of men and women. A more in-depth qualitative study
that seeked to understand the what, how and why of barriers women face when accessing, obtaining and
using contraception was necessary in order to supplement existing literature and implicate more specific
Karen Kayekjian
Bixby Program
Summer 2008
Armenia
policy changes. The IRB approved study entailed in-depth interviews with married men and women of
four villages surrounding Yerevan including Nor Gharberd, Oshakan, Ayntap and Tsaghkashen, as well
as ob/gyns of town hospitals including Masis, Ashtarak and Etchmiadzin. We also conducted two focus
groups with mother in laws of two additional nearby villages, Arindj and Parakar. Questions addressed
feelings and opinions regarding family planning decisions and the promoters and inhibitors of
contraception procurement. Questions for physicians addressed contraception methods and information
provision to clients in the hospital. Although a more thorough and detailed analysis of transcriptions
needs to be conducted, it was clear that couples of rural Armenia heavily rely on traditional methods such
as withdrawal and the calendar method. There seems to be a widespread fear and anxiety about hormonal
methods’ effects on the body including body hair growth and mood changes. Furthermore, only a few
men out of the fifteen interviewed were motivated enough to answer questions about family planning
thoughtfully. Women seemed to portray a general mistrust or lack of confidence in the medical system
and along with men referenced neighbor or friend stories as reasons for not using modern contraception.
Generally women interviewed had had one to two abortions during their lifetime and some had selfadministered Cytotec without the consultation of a doctor. Most women are aware of all methods of
contraception with the exception of hormonal injections but are unfamiliar with the cost of methods. The
handful of women who showed a general trust of medical providers were unfamiliar with the criteria of
contraception methods and were willing to undergo medical tests to obtain oral contraceptives or the IUD
if recommended by the physician. The responses of ob/gyns were mixed and surprising. A few physicians
displayed a strong sense of knowledge regarding the explanation of contraceptives but it was unclear if
that translated into the informed choice of women who are supposed to be offered more than one method
option. Some physicians hardly answered questions during the interview and at times shrugged their
shoulders or gave meaningless answers. The most intriguing responses from ob/gyns included beliefs that
long-term oral hormonal contraceptives are unsafe for the woman’s body, OC’s should only be used for
Karen Kayekjian
Bixby Program
Summer 2008
Armenia
treatment of reproductive conditions and emergency contraception or Postinor offers less harmful side
effects and is more convenient. The small-scale qualitative study shed light on some of the most
prevalent ideas existing today regarding modern methods of contraception as well as offered an insight
regarding family dynamics in villages.
Field observations and participation in the ProjectNOVA four-day training of ob/gyns, nurses and
midwives in Talin hospital highlighted the need for continuous education in the area of family planning
consultation. Although providers have heard of all methods, they are unfamiliar with the
contraindications, procedures of administration and general counseling techniques. The training entailed
PowerPoint presentations, demonstrations of methods, role-playing and a pre and post-test to assess
knowledge gained. Furthermore, interviews conducted with NGOs such as the Women’s Resource Center
and For Family and Health Association highlighted organizations that focus on family planning and
reproductive health awareness through sexual health courses, information pamphlets, family planning
consultations and referrals. After visiting international agency regional offices, it was clear that the WHO
offers technical support in the form of agenda planning and goal setting, while the UNFPA continues to
provide a supply of contraceptive methods to FP consultation centers in Armenia. Despite written
objectives to increase contraception use to 30% as well as increase government spending on contraception
by 2015, (outlined in the Reproductive Health National Strategy, Program and Actions Timeframe 20072015), as the MOH Deputy Minister clearly explained, pregnancy, delivery, neonatal care and children’s
health are currently top priority issues while contraception, STDs and infertility are less important.
Challenges
The institutionalized competitive atmosphere and informal payment system of Armenia posed as one of
the key challenges in communicating with key players as well as gaining a clear understanding of the
situation. Multiple departments, which equally served women of reproductive age, did not mutually
benefit one another and lacked a common goal. NGOs and private organizations did not acknowledge
Karen Kayekjian
Bixby Program
Summer 2008
Armenia
any sort of cooperation, collaboration or connection with one another, hence making it difficult for one to
find common interests between parties in order to draw conclusions about how organizations work with
one another. The last comment pertains to the challenge of conducting a qualitative study in a foreign
country. Conducting in-depth interviews and focus groups in close-knit rural settings such as villages
requires incentives and thorough planning in order to avoid a low response rate and the loss of
confidentiality.