Helping to improve Reproductive Health in Armenia

What's the situation?

Armenia's transition from a republic of the former Soviet Union to Independence had a damaging effect on public and social services including the health sector.

Immediately after independence, Armenia plunged into a period of deep economic depression, exacerbated by an energy crisis, armed conflict, blockade and the continuing financial and social cost of a devastating earthquake in 1988. The crisis, combined with new freedom to travel, led to a huge wave of migration from Armenia, with one million people leaving the country since 1990.

Although Armenia's economy has made a remarkable recovery and the government is striving to reduce poverty, it is unlikely that there will be enough national resources in the near future to expand and improve social services.

Armenia's overall economic fortunes have been mirrored in the country's provisions and services for reproductive health . After a sharp deterioration in the mid-90s, the reproductive health (RH) situation is gradually improving. But Armenia will need further assistance from its development partners, such as UNFPA, to meet many of the RH challenges it still faces

Low quality, unequal access to Reproductive Health and Maternal Healthcare

Despite Armenia's economic recovery, the overall quality of reproductive health and maternal healthcare remains low. This is partly because of low government spending and partly because of the complexities reforms to health and social services which are still continuing.

Access to reproductive and maternal health services across the country is very unequal.

In urban areas, 90 per cent of pregnant women consult a doctor at least once during their pregnancy; but in rural areas this ratio is just 74 per cent. Although the majority of women in Armenia give birth in medical facilities, the ratio of home delivery is much higher among poor women and women living in rural areas, as they have limited access to midwives or other birthing help.

Although maternal mortality decreased throughout the 1990s, there was a peak of 61 deaths per 100,000 in 2000. This was partly due to a lack of timely emergency obstetric care particularly in rural areas. In response to this situation, UNFPA introduced an emergency obstetric service and this, combined with an increase in budget allocations to reproductive health, contributed to the and the maternal mortality rate dropping back to 16.4 in 2003 .

Available data for evaluating the reproductive health situation is sometimes inconsistent.

According to the 2000 demographic and health survey, the infant mortality rate remains high at 12 deaths per 1,000 live births. This survey was conducted by the National Statistical Service and the Ministry of Health, with funding from USAID and technical assistance from ORC Macro, an opinion research company.

Armenian policy-makers have taken a number of important steps towards promoting a rights-based approach to reproductive health and population issues, notably the adoption in 2002 of a Law on Reproductive Health and Reproductive Rights . This set a legal framework for a continued implementation of the rights-based Program of Action of the 1994 International Conference on Population and Development (ICPD) The initiation of a National Poverty Reduction Strategy (PRSP) identifies maternal and reproductive health as priority issues.

UNFPA believes that it is necessary to agree a long-term national strategy to secure funding for programmes for Reproductive Health, including supplies of reproductive health commodities such as contraceptives. Such a strategy would involve the Government of Armenia contributing to and then gradually taking over the reproductive health programme.

Contraception : High levels of awareness low use of modern methods.

Since 1996, when UNFPA assisted in establishing a network of family planning service delivery points across the country, the contraceptive prevalence rate has grown from less than 1 per cent in 1994 to 22 per cent in 2000.

It is now much easier to get reproductive health commodities in Armenia. The public sector has been supplied with modern contraceptives, and some items particularly condoms, pills and spermicides, can be bought from private pharmacies.

But there are still a number of challenges. Although there is near universal knowledge of contraceptive methods (99 per cent of married women), actual use of modern methods is still low.

And for young people and adolescents who are experiencing far more personal and social freedoms than their parents' generation, the cost of contraceptives can be prohibitive. According to the 2002 Knowledge, Attitudes and Practice (KAP) Survey, which was financed by UNFPA , about 20 per cent of sexually active young men and 56 per cent of sexually active young women in Armenia never use contraception. This puts them at great risk of unwanted pregnancy, abortion, sexually transmitted infections or HIV/AIDS. For more about the specific issues affecting young people in Armenia, click here.

Despite an overall increase in the availability of contraceptives, the rate of induced abortion in Armenia is still high it is estimated that 51 per cent of pregnancies terminate in abortion. Secondary infertility has reached 31 per cent, with many cases likely to have resulted from complications after abortions. Post-abortion care and counselling are very limited.

A high risk region for Sexually Transmitted Infections and HIV/AIDS

Both men and women in Armenia are at increasing risk of sexually transmitted infections. Armenia belongs to a region within which HIV/AIDS is spreading fast and its population is further endangered by the fact that it has close migration ties with countries with dangerously high STIs/HIV/AIDS growth rates, i.e. Russia and Ukraine .

In recent decades there been an increase in sexually transmitted infections (STIs) in Armenia, particularly syphilis, gonorrhoea, chlamydia, and trichomoniasis.

Although the surveillance and treatment system for STIs was disrupted during the initial post-independence years, the Ministry of Health is introducing a "syndromic approach" to diagnosis, which is based on risk factors and client symptoms, not necessarily on laboratory findings. The syndromic approach can be helpful in areas with low resources and few laboratory facilities, but it has limitations and comprehensive diagnosis remains the best strategy for STI management .

As of June 2005, 315 HIV infected people have been registered in Armenia. However, the unofficial estimate of people living with HIV/AIDS in Armenia is about 3000.The main causes of transmission are injecting drug usage and sexual transmission between men and women.

The government of Armenia has taken a number of important steps in recognising that HIV/AIDS can threaten national development. The first National Strategic Programme on HIV/AIDS was adopted in 2001. HIV/AIDS was also highlighted as a priority area in the Poverty Reduction Strategy Paper (PRSP) an important step in encouraging both the government and civil society to take action.

Over the last 5 years, the government of Armenia has improved its institutional capacity to address HIV/AIDS by establishing a management and coordination mechanism at both regional and national levels. It has also established a surveillance system, which tracks HIV/AIDS cases, and monitors and evaluates the effectiveness of HIV/AIDS programs.

However, despite these positive developments, Armenia still faces considerable challenges if it is to prevent HIV/AIDS from spreading.

One problem is that state allocations towards preventing HIV/AIDS are still very low. Coordination of activities and programmes is often poor and in many cases the people who have to administer these programmes lack of knowledge or skills.

Decision-makers need to be made aware that a multi-dimensional effort is needed to address HIV/AIDS. Currently many government and civil society workers view HIV/AIDS as a purely medical problem or as something which only affects certain high risk groups such as commercial sex workers

Another issue which still needs to be addressed in Armenia is a tendency to stigmatise and discriminate against people who have HIV/AIDS. This is a violation of their human rights and can lead to their social exclusion.

Young people a lack of information and access to RH services

During the Soviet period and the years immediately after independence, education on sexual and reproductive health for young people was largely ignored.

The Knowledge, Attitudes and Practices (KAP) survey, conducted with the help of UNFPA in 2002 showed clearly that young people in Armenia lack the knowledge and skills for making informed choices about their sexual and reproductive behaviour.

For young people in Armenia, getting accurate information about sexuality or sexual health is difficult. Only 18% of young people questioned in the survey said that their parents had given them information about sexuality or sexual health. For many, the main sources of information have been peers and magazines.

However it seems that many parents and young people would be happy if this issue were addressed in school classrooms. In the same 2002 KAP survey, 88 per cent of adults and young people were in favour of introducing sex education into the general school curricula and most of them said they were sure that this would not have a negative influence on the sexual behaviour of adolescents.

Despite this positive response, actual progress in the state education system has been very slow. The Ministry of Education and Science plans to introduce a "H ealthy Lifestyle " curriculum, which will include sexual and reproductive health, into state schools in 2006.

Aside from information, young people in Armenia need greater access to services for sexual and reproductive health. At present the public health system offers very few health services which are specifically youth-friendly. Young people's access to other existing services for sexual and reproductive health is limited, mainly by cultural stigmas associated with adolescent sexuality and by financial constraints.

While contraceptives, including condoms are now for sale in pharmacies, many young people find them too expensive. Many young people who are sexually active (20 per cent of young men and 56 per cent of young women, according to the KAP survey simply don't use contraception. This puts them at risk of unintended pregnancy, abortion, sexually transmitted infections and HIV/AIDS.

The Government of Armenia has identified three key issues which must be addressed in order to meet the sexual and reproductive needs of young people:

• Local authorities, civil society and media need to provide more support for SRH education and youth-friendly initiatives.
• Teachers, other educators and health providers need to improve their knowledge, communication and counselling skills on issues related to sexual and reproductive health.
• Young people including more vulnerable groups need better access to information on sexual and reproductive health and gender issues, to youth-friendly counselling and care and to affordable contraception.

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