ARMENIAN CASE STUDY
Presented by “Confidence” Health NGO –member of IBFAN
by Susanna Harutyunyan
1.
BACKGROUND
a)
Country situation
The Republic of Armenia is a mountainous country, located in the Southern Caucasus Region of
Eastern Europe, with Georgia, Turkey, Azerbaijan and Iran as neighbors. It is the smallest of the
republics of the Former Soviet Union (FSU), with a total land area of 29,800 square kilometers.
The total population is about 3,766,400. The population is primarily ethnic Armenian, the
official language is Armenian. The overwhelming majority of Armenians are Christians,
belonging to the Armenian Apostolic Church. One third of the population lives in Yerevan,
another third in other urban areas. Armenia declared independence from the Soviet Union in
1991 and became a democratic sovereign state.
Country social-economic status: Before the economic transition, the majority of Armenian
population enjoyed a comfortable lifestyle. Health care, education and utilities were provided by
the state. State salaries were decent and families could afford yearly vocations. Poverty certainly
existed but it did not affect the majority of the population.
Immediately following the independence, the breakdown of the central planning system and
disruption of trade and production, led to a severe drop in living standards and a rise in poverty
throughout the country. The social and economic problems were compounded to 2 additional
factors: the effects of 1988 earthquake that killed at least 25,000 people, left another half million
homeless and destroyed 40% of the production capacity; and armed conflict between Azerbaijan
and Nagorno-Kharabagh, which resulted in economic blockade against Armenia and the influx
of over 350,000 refugees.
The events of the last decade that had changed the economic situation in the country as a whole
had a deep effect on individual family incomes. Many of the people now living in poverty lost
their homes and possessions as a result of the earthquake or war. Many lost their savings in early
1990s when inflation was out of the control and the banks collapsed. Others were thrown into
unemployment when the industrial sector collapsed. In 1991, in addition to the economic crisis,
Armenia suffered a severe energy crisis, which made the living conditions of the population
extremely difficult with no electricity and heating sources in houses. The stabilization of the
energy supply began in 1995.
The poverty assessment study conducted in November-December 1996 revealed that 54,7% of
the population in Armenia was leaving in poverty, among them 8,5% - extremely poor.
Now despite the growing economy and steady recovery on a macro level, there are no effective
mechanisms in place to assist families out of poverty. The benefits of economic growth have not
been enjoyed by the whole population and polarization of the society is apparent.
Women’s work situations: The Armenian government has enacted legislation at achieving
gender equality and protection of women in work setting. The laws regarding gender equality
include guarantees for equal consideration for promotion, equal pay, and free choice of
profession without discrimination. Protection measure for women, mothers and families include
paid maternity leave (70 days before and 70 days after giving birth, with benefits amounting to
100% of salary, paid by the government), guaranteed employment and earning, creation of
special work conditions for pregnant women and breastfeeding mothers, and extension of some
benefit to fathers.
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Women’s unemployment: Although the official rate of unemployment was 10,6% in 2003,
hidden unemployment rate is estimated to be between 25 to 28%. The majority are from urban
areas (94,3%), women make 71% of unemployed. There are several patterns of unemployment
for Armenian women. The phenomenon of voluntary unemployment has become widespread in
the past few years. Because of the low salary levels and poor work conditions, some women
prefer to leave work and engage in business and little trade (unregistered work). This has become
common and is a major source of income for many families. This is somewhat different in the
earthquake zone and border areas, where work is scare and any job is welcome.
Family structure, the role of the women and men in the family: Armenian society is
traditionally centered around the family. The most common family structure before the 1980s
was the three generation household, with parents, children and grandparents living in the same
house. The aging parents usually lived with youngest son and only rarely with daughter. In the
1980s the proportion of the two-generation families in urban areas began to increase but this
trend slowed significantly in the early 1990s due to the economic hardships. Although the three
generation household is still the predominant model, a variety of alternative household structures
have been formed as families struggled to cope with the economic situation. Multiple brothers
and their families are living with their parents under one roof due to luck of resources to buy or
rent new apartments. There are also many single-generation households in which the able-bodied
family members have temporally or permanently emigrated, leaving aged or single family
members behind. Single parent households have also increased due to emigration and an
increased number of children born out of the wedlock. These changes in family structure have
considerably weakened the family support mechanisms.
In the Armenian family the men has traditionally been the head of the household and the main
income earner, while the primary role of women was to bear children and raise the family. In
traditional three generation families grandmothers usually assist young mothers in house work
and child care, including breastfeeding. Although the traditions remain strong, especially in rural
areas, they started to change under the soviet system. Contributing to this change was the
exceptionally high level of literacy and education attained by women and the increased
participation of women in economic and political activities. In the past decade the difficult
economic situation in the country has further increased the role of women in income generation
at the household level.
In general, the desirable amount of children is two in urban areas and three-four in rural areas.
As in most cultures, the birth of a boy is more desirable than a girl. The son is perceived as the
preserver of family traditions, since he often lives with the parents after marriage, while the
daughter leaves the family to join her husband’s family.
Women and children nutritional and health status: According to the national nutrition survey
conducted in 1998 in Armenia 5% of children suffered from acute malnutrition, (low weight for
height). The prevalence rates for stunting (low height for age) were much higher ranging from
9,1% in the urban areas to 15,5% in rural areas. The later is an indication of chronic malnutrition
and vitamin deficiency. The survey showed that one third of women aged 23-45 years of age are
overweight or obese. Underlying cause of obesity could be the high fat diet in Armenia
combined with low level of physical activity and exercise among women. The prevalence of
malnutrition in women 23-45 years was about 5%.
The survey assessed the levels of micronutrient deficiencies. Mild/moderate anemia was
observed in 26% of children aged 12-23 months and 25% of the children aged 24-59 months and
15% of women in the 15-45 age group. The prevalence of anemia was significantly higher in
rural residents and rural refugees. Anemia was very common in pregnant women with rates
increasing as the pregnancy progressed. During the third trimester of pregnancy, prevalence of
anemia ranged between 43% (rural residents) and 71% (urban refugees).
Iodine deficiency disorder (goiter) was observed in 30% of women, 6% at the visible stage.
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Considering the devastating effect of iodine deficiency on fetal development, the high proportion
of women in childbearing years that is suffering from this disorder is alarming.
The official natural growth rate in Armenia declined 67% between 1990 and 1997. This is due to
sharp decrease in the official birth rate of 48%. Since the majority of births in Armenia are to
married women, some of the birth rate decline can be explained by the changing marriage
patterns in the country. The marriage rate has declined by nearly 50% since 1990. Migration,
military service and the difficult social economic situation are all factors contributing to this
decline.
There have been marketed improvements in key indicators for child health over the past few
years, including a decrease in infant mortality and under five mortality rates, an increase in
breastfeeding rates. According to official (governmental) statistics infant mortality rate in 2002
was 15.5 ‰ perinatal mortality rate 16.7 ‰.
Support from family/men/community for breastfeeding: Armenians are considered to be a
traditionally breastfeeding nation. Before the soviet rule early initiation of breastfeeding,
exclusive breastfeeding and breastfeeding for more than one year was a norm. Women who were
not breastfeeding and childless women were to some extent aliened from the family and society.
The family and especially grandmothers were fully supporting young mothers in initiation and
maintenance of breastfeeding and helping them in child care and house work.
During the soviet time traditional soviet breastfeeding methods such as late initiation of
breastfeeding, scheduled feeding, routine prelacteal feeding with water, glucose water, donor
milk and formula, use of bottle-feeding & dummies were introduced and the prevalence of
breastfeeding declined during the years of Soviet rule. Modern Armenian grandmothers are for
breastfeeding but their knowledge and beliefs sometimes harms more than helps. Majority of
them believe that infants need to be fed each 3-3,5 hours once with 6 hours night rest. They are
very concerned about insufficient breastmilk and whenever the infant cries more than normal or
demands breastfeeding more than usual, recommend water, juice, tea and formula or cow’s milk
supplementation. However the family is usually very proud of breastfeeding mother. Armenian
women usually prefer to breastfeed in private situation but when needed they breastfeed in public
places, such as airports, railway stations and there is no stigma involved in breastfeeding in public.
b)
Specific situation of women in Armenia during the period of 1988- 1995
This case study is about the Armenian women who were enjoying a comfortable lifestyle during
soviet period but since 1988 suddenly appeared in a very difficult socio-economic condition due
to devastating earthquake, economic transition and war. Continues stress, shortage of food,
absence of electricity and heating in houses made the living conditions extremely difficult.
2.
COMMON INFANT FEEDING PRACTICES AND FACTORS THAT INFLUENCE
INFANT FEEDING DECISIONS
a)
Country situation
Armenian babies are normally born in maternity hospitals or other health facilities providing delivery
services and extremely rarely in some villages a number of births are home deliveries, when rural
residents are not able to afford both the transportation costs and other associated costs incurred by an
extended hospital stay in a location far from their residents’ home.
During Soviet time immediate initiation after delivery was prohibited and in fact only 13% of mothers
saw their babies within 6 hours of delivery. Before 1993 exclusive breastfeeding was almost non existent.
Infant formula was freely distributed in delivery hospitals contributing to high rates of prelacteal feeds
(70%). Rooming in was not practiced in any hospital of the Republic and schedule feeding with no night
feeding was a norm.
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In 1993 drastic policy changes were announced by the Ministry of Health, which endorsed a program
based on the UNICEF/WHO Baby Friendly Initiative’s Ten Steps to Successful Breastfeeding. MOH
adopted a degree, concerning the implementation of 5 steps of the BFHI in all maternity
hospitals of the Republic with the gradual implementation of the other 5 steps in parallel with
training. Immediately implemented steps were early initiation of BF, rooming-in, feeding on
demand, no drinks and food to new-born except the breast milk, exclusion of bottles and
dummies.
A Demographic Health Survey (DHS) conducted in 2000 by MOH and UNICEF showed
impressive changes from 1993, including the following figures:
Breastfeeding rates (DHS, 2000)
- Initiation to breastfeeding:
- Any breastfeeding till 4 months:
- Exclusive breastfeeding at 4 months:
- Full breastfeeding (exclusive + predominant):
- Continued breastfeeding at 8-9, (10-11), (20-23) months:
- Mean duration of breastfeeding:
- Bottle feeding at 4 (4-9) months:
98- 99%
95%
45%
74%
54%, (35%), (12%)
9 months
34% (50%)
There are marketed improvements in exclusive breastfeeding rates since 2000 but no other
comprehensive study of infant feeding has been conducted since than.
Patterns of infant feeding in different age groups (DHS, 2000)
94
24-35 mon.
87,5
20-23 mon
12,5
78,3
16-19 mon.
21,7
71,2
12-15 mon.
28,8
65,3
10-11mon
4,9
< 4 mon.
0
2,6 6,2
49,5
29,7
4-5 mon.
48,4
21,5
2,1
31,6
39,1
6-9 mon.
Not BF
6
12,5
20
BF + other liquids or food
14,2
16,6
40
2,6
3,6 4,1
44,5
60
BF+ liquids/ jucies
80
BF+ water
100
Exclusive BF
Infant feeding options to 4 months of age (DHS, 2000)
BM and water
17%
BM and other
liquids
13%
BM and
other milk
14%
Exclusive BF
43%
BM and
complementary food
8%
Not BF
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If the baby is bottle fed with formula baby’s food will cost equivalent to 30-60 USD per month.
In rural families this amount is comparable with the total income of the family and cow’s milk is
often chosen as an alternative option. Normally adequate clean water, sanitation and hygiene in
the home are available, except for extremely poor families or families living in temporary
housing.
A big obstacle for improving exclusive breastfeeding rates is the availability of infant teas from
one week and other infant food from an early age (especially from the company HIPP). Many
mothers believe that HIPP teas can help in colic or the infant may be thirsty if is not given water
in addition to breastmilk or the young infant needs fruit juices as a good source of vitamins
starting from 40 days. Concerns about insufficient milk supply are also common and lead to
early supplementation. Alertness, not crying, regular stools and urine are the traits in the baby
considered to be most important. Other liquids are usually introduced by a bottle.
Feeding decisions are usually taken by the mother/parents of the infant and are the most
influenced by health workers, mother in low, personal experience, economic factors, commercial
pressure and tradition.
b)
Specific situation of women in Armenia during the period of 1988- 1995
Since 1988 in parallel with the drop in living standards in Armenia a drastic decline in
breastfeeding rates was observed. While in 1988 64% of all infants were fully breastfed at the
age of 4 months, in 1993 this figure dropped to 23%. Several reasons such as shortage of food,
economic hardship and continuous stress were given to explain this decline. The majority of
mothers of young infants was reporting insufficient breastmilk, and was requesting infant
formula, because they lacked confidence in their breastfeeding capabilities under such hard
living conditions.
During 1990’s the Ministry of Health (MOH) of Armenia, USAID and other international aid
organizations urgently appealed for donations of infant formula for Armenian infants. These
requests were made with the assumption that mothers were unable to breastfeed due to the recent
socioeconomic changes in the region. Many international organizations replied to this request
and during early 1990’s Armenia was totally provided with infant formula received by
humanitarian aid. The availability of free infant formula was one of the most important reasons
for the decrease of breastfeeding rates. Other important reasons included hospital practices,
unfavorable for breastfeeding, lack of trained medical staff, capable to help mothers with
common breastfeeding problems, lack of knowledge in the population and primary health care
providers about the advantages & management of breastfeeding.
The flood of freely distributed formula has ceased at the end of 1995 due to the policy adopted
by the MOH and to the change of donor strategies by aid organizations. The effect of lack of
formula reinforced other breastfeeding promotion activities.
The cessation of import of breastmilk substitutes through humanitarian aid was closely followed
by commercial imports, with the accomplishing advertising on all forms of media. Unethical
marketing of infant food, including advertisements on TV, promotion in health care facilities and
point of sale promotion, funding of conferences for doctors, numerous violations in
informational materials intended for health professionals and mothers, sale of unsuitable for
infant feeding products with misguiding labels, such as infant teas marketed as suitable to be
given to newborns 1 week after birth, fruit and vegetable purees - 9 weeks after birth, porridges,
cereals, potato and meat purees – 4-5 months, undermine exclusive breastfeeding and do so
much harm in Armenia.
In 1998 the Ministry of Health of Armenia submitted a draft proposal to the National Assembly
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with amendments to the law on advertisement. 1n 1999 National Assembly adopted a new article
on marketing of breastmilk substitutes which was added to the existing law on advertisement.
However there are no mechanisms to stop the violations under the new legislation and the need
for a new, complete and strong Law on Marketing of infant food is apparent.
Since 1996 numerous training programs were implemented with UNICEF support (e.g.
WHO/UNICEF 40 hour course on “Breastfeeding Counseling”, BFHI 18 hour course, Infant and
young child nutrition counseling).
Starting in 1999 the BFHI is implemented in maternity hospitals and 15 maternity hospitals are
certified as BF. In 2003 a new initiative – Baby Friendly Policlinic Initiative was developed and
implemented in Armenia. 2 policlinics are certified as Baby-Friendly.
As a result of those new polices towards promotion and protection of breastfeeding impressive
changes have been registered. in breastfeeding trends. The official governmental statistics shows
the following figures of full breastfeeding rates (exclusive breastfeeding + predominant
breastfeeding) in Armenia.
68
59
57
47
41
37
23
54
46.5 50.3
69
74
60
30.6
20
19
88
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
80
70
60
50
40
30
20
10
0
Percentage of fully breastfed infants to the age of 4 months
CHALLENGES AND WOMEN’S RESPONSE TO CHALLENGES
3.
Armenian women faced a number of challenges:
-
Not loosing the confidence in own breastfeeding capability was a challenge when
everybody including health care providers believed that if the woman has a simple diet or
is undernourished she can not produce enough milk and even if the amount is enough the
composition may be changed and in that case formula can be better for the infant. There
was also a belief that breastfeeding is impossible due to continuous stress in women
living in border areas affected with war.
-
Availability of free infant formula, which could easily get each mother, was another
challenge. Many mothers at first used formula for preparing food for their older children
but when they had a minor breastfeeding problem they tried formula, which decreased the
amount of breastmilk they gave to infant and breastmilk dried up.
-
Health care providers did not have appropriate knowledge and skills to support mothers if
breastfeeding problems arise. The opposite- their misconceptions regarding early
supplementation, insufficient milk and multiple breastfeeding contraindications were
harmful.
-
Difficult living conditions with no electricity, no heating and cooking fuel, not regular
supply of drinking water and poverty made house work and child care very hard work for
young mothers, especially in cases when they didn’t have the traditional help from mothers in
low. Challenges were even more for refugees and for those who loosed their houses
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during earthquake and lived in temporary housing.
-
Unemployment forced many households to migrate temporally or permanently, mostly to
FSU countries, to look for work. Some of them were supporting families that remain
behind in Armenia others did not return. This often resulted in break up of families and
increased the number of single mothers without extended family support.
98- 99% of Armenian women choose to breastfeed their infants however in 1994 at 4
months of age only 23% continued full breastfeeding as a result of multiple challenges they
faced and luck of support.
4.
REASONS FOR PERCEIVED SUCCESS
“Confidence” Health NGO was founded in Armenia in 1998 and deals with protection and
promotion of breastfeeding and optimal infant feeding practices. Confidence is a member of
International Baby Food Action Network (IBFAN). In collaboration with Ministry of Health of
Armenia and international organizations (e.g. UNICEF and IBFAN) Confidence carries out the
following activities:

Continuous monitoring of company compliance with the International Code and relevant
resolutions.

Advocacy for implementation of the Code and resolution at national level.

Education and information activities: training courses for health workers

Implementation of Baby Friendly Hospital and Baby Friendly Policlinic Initiatives

Supporting health workers and parents in their right to independent information regarding infant
feeding.

Development and publication of literature for health workers and general public on breastfeeding,
International Code and other aspects of infant feeding.
The monitoring of the Code in Armenia, carried out by Confidence in 2003 reported many
violations of the International Code and subsequent resolutions. Following the monitoring report
letters were sent to the headquarters of major violators of the Code in Armenia- Nestle and HIPP,
in behalf of the MOH of Armenia, WHO and UNICEF Armenia country offices. As a result
Nestle has made several positive changes in its marketing practices.
Confidence Health NGO closely participated in development of Baby Friendly Policlinic
Initiative (BFPI).
The ten steps of BFPI are:
Pediatric polyclinics intending to become BABY-FRIENDLY should:
1.
Have a written policy on infant and young child feeding that is routinely
communicated to all health care staff.
2.
Train all health care staff in skills necessary to implement this policy.
3.
Inform all pregnant women about the benefits and management of breastfeeding.
4.
Regularly perform breastfeeding screening at estimated dates and support mothers in
initiation and maintenance of breastfeeding.
5.
Promote exclusive breastfeeding for 6 months and continued BF for 2 years or more.
6.
Promote demand feeding.
7.
Provide mothers with necessary information on timely, adequate and appropriate
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complementary feeding.
8.
Inform mothers of infants who are not breastfed about safe and appropriate alternative
feeding options.
9.
Comply with all provisions of the “International Code of Marketing of Breastmilk
Substitutes”.
10.
Encourage and support mothers to breastfeed by fostering the establishment of
breastfeeding support groups and by spreading information about new approaches in
infant and young child nutrition among the population.
With the support of UNICEF Confidence members developed a new training module on “Infant
and young child nutrition counseling” and assessment tools for BFPI
In 2004 two pediatric polyclinics are certified as Baby Friendly. According to the reports of the
authorities of first policlinic certified as BF the breastfeeding rates in the policlinic are the
following:

Exclusive BF at 4 months – 95,8%

Exclusive BF at 6 months – 95,4%

Continued BF at one year – 78,1%

BF at 2 years 33%
These data were proved during the assessment of the policlinic carried out by the team of
assessors for BFPI (all Confidence members).
The other policlinic showed similar results.
5.
6.
LESSONS LEARNT

Availability of free formula in crisis situations can dramatically decrease breastfeeding
rates.

Comprehensive programs in breastfeeding promotion should include measure to protect
breastfeeding from misleading commercial promotion from baby food manufacturers.

Companies may change their practices under the pressure of NGOs and public opinion
when systematically monitored, even if the country has not adopted an effective
legislation on marketing of infant food yet.

The implementation of Baby Friendly principles in pediatric health care institutions has a
very positive impact on prevalence of breastfeeding due to the continuous information
and support that mothers get during the whole period of childbirth and infant care. BFPI
can be considered a very effective alternative to the 10th step of BFHI in countries where
women support groups are traditionally difficult to implement.

Confidence Health NGO plans to continue its activities in implementation of the
International Code and BFH and BFP initiatives as those activities are proved to be very
effective in respect of breastfeeding promotion and protection.

BFPI can be effectively introduced in other countries that have similar to Armenia health
care system e.g. FSU countries.
KNOWLEDGE OF OTHER PROJECTS
There are numerous NGOs in Armenia engaged in maternal and child health and breastfeeding
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promotion is often part of their projects. They usually offer training for health personnel of the
institutions where they work and maternal education in the sphere of infant nutrition and care.
Those projects are usually effective but the number of beneficiaries is usually limited.
Confidence has collaborated with Family Care- a local NGO which implemented mother and
child health protection programs in several regions of Armenia. They carried out health
personnel trainings in 9 maternity hospitals and published literature for mothers on infant
feeding. Three of those hospitals where Family Care provided training are certified as Baby
Friendly.
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