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The Story of Two Sisters: A Perspective on the Abortion Issue in Armenia
11:14, March 15, 2013
I first encountered Lilit, a mother of two in her mid-twenties with an
extraordinarily bright smile, on a day that felt like the very
beginning of winter.
I would encounter her three more times on equally frigid days over the
course of a few months. On that particular day, I had accompanied the
Children of Armenia Fund staff on one of their reproductive health
rounds. For three months each year, COAF (http://www.coafkids.org)
provides gynecological exams free of charge for all interested women
in each of their target villages.
On that day in late November, Lilit and I found ourselves sitting
together in a small room at the village health post. Two friends of
hers had also joined us. We all sat down in the nurses' office, a
barren room with a desk and a few chairs. The women sat on the edges
of seats, as if in a crowded mashrutka. There was no electric heater
in the room, so we all kept our winter coats on and huddled closely
together. It was under these less-than-favorable conditions that we
began to speak about reproductive health. Each woman had her own
unique story. We talked, we laughe, and we exchanged notes. I
described the importance of family planning and each contraceptive
method available to them.
I returned back to the same village in January to interview women for
my research study. Lilit's was a familiar face. She had arrived that
day accompanying her sister-in-law, who was experiencing complications
from the use of medical abortion.
Medical abortion has been shown to be efficacious in controlled
settings under the supervision of a medical professional. This seems
to rarely be the case in Armenia, where women have easy access to the
drug, Cytotec (misoprostol),and a few pills that cost under two
dollars (a fraction of the price of a surgical abortion) is enough to
induce an abortion. Cytotec is indicated for an entirely different
medical condition but has been used off-label for roughly the last
half decade in Armenia to induce abortions. It is thought that the
number of women resorting to this method is higher than ever before.
Lilit's sister-in-law, like many other women I met, did not receive
counseling from a medical professional and had taken a greater dose
than recommended. In fact, all of the women with whom I have spoken
who have used Cytotec have reported using entirely different dosages.
Even the pharmacist in one of the villages had no clue what the
recommended dosage was. She always insisted to her clients that they
should seek medical care for an abortion, but she would still readily
sell any amount to any woman who asked for it.
The World Heath Organization (WHO), realizing that the use of medical
abortion is growing worldwide, has published a series of specific
recommendations based on which drugs are available and the gestational
age of the fetus. Best practices encourage the use of two drugs,
mifepristone and Cytotec, in combination. The former is not widely
available in Armenia due to its higher cost, and, because treatment
with Cytotec is less effective, women are often forced to have a
surgical abortion after suffering complications. A midwife who works
in one of villages told me that she didn't believe that the drug was
effective at all due to her experience treating women who had misused
it.
I sat down with Lilit again. She told me that she was two months
pregnant. She had actually been pregnant at our previous session but
wasn't aware at the timet. She had two abortions when her children
were young. Shortly after having her second abortion, she decided to
have an intra-uterine device inserted.
According to the 2010 Armenia Demographic and Health Survey, it is
estimated that 3 in 10 pregnancies in Armenia end in abortion, though
this figure is likely underestimated.
Birth spacing, along with socioeconomic conditions, are tied as the
second most common reasons women report having abortions. The most
common is the desire not to have any more children. These statistics
highlight the dramatic unmet need for family planning. However, Lilit
is representative of many of the women with whom I'm spoken who have
used or have thought about using an intra-uterine device, which is
growing in acceptance as a method of fertility control. Considering
that women are limited in terms of the affordability, availability,
and accessibility of contraceptives, as well as their aversion to
certain contraceptives, the intra-uterine device poses as a potential
gold mine in these villages.
After five years had passed, Lilit decided to have the intra-uterine
device removed. Her two children had already grown up quite a bit and
her financial condition was relatively stable, so she was ready to
have more children. Halfway through our interview, the topic of
sex-selective abortions came up. I asked her whether or not the sex
of the fetus was important to her, to which she giggled nervously and
simply responded, `Yes'.
Many women in the villages of Armenia have told me that they must have
a son. I hear over and over again the phrase, `I have two girls; the
next one must be a boy.' Some women say that they want one boy and
one girl. Others say that they will keep trying (and often keep
having abortions) until they have a boy.
One woman even expressed to me that she was so fearful of the prospect
of having another sex-selective abortion that she preferred not having
any more children at all, even though she had originally planned to
have a bigger family and wanted a son.
In a study carried out by the
UNFPA(http://unfpa.am/en/unfpa-in-armenia), survey results show that
families primarily choose sex-selective abortions because sons
continue the family lineage, are inheritors of property, and provide
financial support. In simplified terms, this means that the roles men
play in Armenian society dictate their inherent value for families, at
least families that remain traditional.
Now, before you make any judgments about Armenian women who choose
sex-selection, let me propose this scenario to you.
Imagine that you are a twenty-seven year old woman living in a rural
village. You've already had two children. One is seven years old and
the other is five. Now that they're old enough to go to school, you
help out your family by growing fruits and vegetables and making
lavash to sell.
Your body constantly aches. You have a fairly good relationship with
your mother-in-law, but she's getting older and all of the household
chores rest on your shoulders. You use family planning sometimes, but
not all the time. It's more or less up to your husband and you don't
challenge him, because you think that whatever works for him, works
fine for you. You find out that you're pregnant.
Meanwhile your husband has left the country to work as a seasonal
migrant, and you're left alone with two children to feed, clothe, and
nurture; work in the field; a house to clean; and your elderly in-laws
who depend on you. You can't imagine raising another child, at least
not now. But you have two daughters and you know that it's really
important to your family to have a son. They talk about it around you
all the time. You think that perhaps, if you have a son, at least
he'll stay in the home with you and his wife, your daughter-in-law,
will help you manage. Your daughters will get married and move out of
the village when they reach the age of 18 or 20. Maybe you'll see
them once in a while, but they'll be busy with their own families.
Maybe, when you have a daughter-in-law, you won't be as overburdened
with work. You'll have security, which means that you'llnever end up
in a dreaded old age home with no loved ones, no running water, and an
air of hopelessness... The `choice' becomes rather simple, doesn't it?
But lets get back to Lilit. Her case was a little different. She
already had one boy and one girl, but was intent on having a second
male child. She said that she wanted her son to have a playmate, a
brother with whom he could share everything.
She said that it was important for her daughter to have a sister as
well. Ideally, she would have two boys and two girls, but the sex of
the fourth child wasn't as important. It was clear to methat she
didn't want to get too attached to her pregnancy until she knew the
sex. She said that the only pressure she felt came from herself, but
it was clear to me that she wanted to fulfill her family's wishes.
After all, her mother-in-law had given birth to two boys and two
girls, and her entire family was rooting for a boy.What could I say?
She was determined to have another son, despite everything I had told
her about the risks of having a late-term abortion and despite the
fact that she already had one son. I thanked her for her time and
accompanied her out of the room. Afterwards, I met with her
sister-in-law and encouraged her to immediately get checked-up at the
nearby hospital. She had been suffering from complications from using
Cytotec for two months by the time we met.
A month later, I bumped into the two sisters at the hospital. I
recognized Lilit's bright-colored coat, her pale pink lipstick, and
that winning smile of hers. I turned to her sister-in-law and asked
if everything was fine with her health. She giggled nervously and
said that she didn't see a doctor because, soon after our session, all
of her symptoms went away.
I tried to convince her that she would need to get checked up in order
to ensure that she had a complete abortion, that she didn't have an
infection, or worse... but she brushed me off. She felt fine. Why
should she see a doctor? Then it suddenly occurred to me why they
were at the hospital. I had seen Lilit when she was two months
pregnant. Now, a month later, it was the beginning of her second
trimester, and she was there to check the sex of the fetus. I looked
over at her. looked anxious. I make a quick remark about reconsidering
the decision, to which she smiled and nodded. I had to get back to
work, but Lilit remained on my mind. As soon as I had the chance, I
rushed downstairs to the sonogram room to find her, but she had
already left.
Fast-forward another month. I was back in the village health decided
to sit in on a health education session for pregnant mothers. There
was Lilit again, squeezed in between ten or so other women who had
come to participate. We made eye contact and greeted one another. I
didn't ask her whether she was having a boy or a girl. I was pretty
sure that I knew the answer and didn't want to prod. Nevertheless, I
was happy for her. At one point during the session, the topic of
sonograms arose. The doctor noted that sonograms are never completely
reliable in determining the sex of the fetus, even after several weeks
of gestation. I looked over at Lilit. I could tell that she was
trying to hide any signs of anxiety. It was evident that she was
thinking,what if?
Whereas I empathize with Lilit, I envision a different what if. What
if one day the sex of the fetus doesn't matter.What if the estimated
1,400 girls, who, according to the UNFPA are not being born each year,
have the chance to exist? What will it take to get to that point?
Well, I believe that a number of factors are simultaneously needed to
move past sex-selection. There is no easy fix. Though many women have
told me that sons are important for ensuring stability for aging
parents and for continuing the family line, others have told me that
the importance given to male children is simply an Armenian
phenomenon, a practice that is highly engrained in society and one
which they struggle to describe in a meaningful way.
What if medical abortion was more controlled? What if best practices
were used? What if all women were educated about the risks of taking
abortion into their own hands?
I'm convinced that we need a three-pronged approach to tackle the
abortion issue - one that combines large-scale education campaigns
with better affordability, accessibility, and availability of
contraceptives and initiatives that empower women and help them
support their families.
Inevitably, providing women with greater opportunities will raise
their morale and give their families greater financial means, which
will enable them to provide for their existing children and consider
having a larger family. (Most women in Armenia will tell you that
they have fewer children than they desire due to current economic
conditions.)
Logically, the economic component in and of itself will help reduce
the number of abortions, sex selection included. If a woman chooses
to have a larger family, that means fewer abortions. It also means
that the likelihood of having both male and female offspring will be
greater.
But economics aside, lets consider the human component. Women will be
more knowledgeable and have greater choice when it comes to having
children and using contraception.They will have the opportunity to
envision a greater role for themselves in society. And girls will be
raised in a society that finds greater value in them.
The math is pretty simple. More investment in the health and
wellbeing of women and girls means a greater future for them and for
their families. What if.
Ani Jilozian
Fulbright Research Fellow
Masters of Public Health Student
http://hetq.am/eng/articles/24468/the-story-of-two-sisters-a-perspective-on-the-abortion-issue-in-armenia.html
From: A. Papazian
11:14, March 15, 2013
I first encountered Lilit, a mother of two in her mid-twenties with an
extraordinarily bright smile, on a day that felt like the very
beginning of winter.
I would encounter her three more times on equally frigid days over the
course of a few months. On that particular day, I had accompanied the
Children of Armenia Fund staff on one of their reproductive health
rounds. For three months each year, COAF (http://www.coafkids.org)
provides gynecological exams free of charge for all interested women
in each of their target villages.
On that day in late November, Lilit and I found ourselves sitting
together in a small room at the village health post. Two friends of
hers had also joined us. We all sat down in the nurses' office, a
barren room with a desk and a few chairs. The women sat on the edges
of seats, as if in a crowded mashrutka. There was no electric heater
in the room, so we all kept our winter coats on and huddled closely
together. It was under these less-than-favorable conditions that we
began to speak about reproductive health. Each woman had her own
unique story. We talked, we laughe, and we exchanged notes. I
described the importance of family planning and each contraceptive
method available to them.
I returned back to the same village in January to interview women for
my research study. Lilit's was a familiar face. She had arrived that
day accompanying her sister-in-law, who was experiencing complications
from the use of medical abortion.
Medical abortion has been shown to be efficacious in controlled
settings under the supervision of a medical professional. This seems
to rarely be the case in Armenia, where women have easy access to the
drug, Cytotec (misoprostol),and a few pills that cost under two
dollars (a fraction of the price of a surgical abortion) is enough to
induce an abortion. Cytotec is indicated for an entirely different
medical condition but has been used off-label for roughly the last
half decade in Armenia to induce abortions. It is thought that the
number of women resorting to this method is higher than ever before.
Lilit's sister-in-law, like many other women I met, did not receive
counseling from a medical professional and had taken a greater dose
than recommended. In fact, all of the women with whom I have spoken
who have used Cytotec have reported using entirely different dosages.
Even the pharmacist in one of the villages had no clue what the
recommended dosage was. She always insisted to her clients that they
should seek medical care for an abortion, but she would still readily
sell any amount to any woman who asked for it.
The World Heath Organization (WHO), realizing that the use of medical
abortion is growing worldwide, has published a series of specific
recommendations based on which drugs are available and the gestational
age of the fetus. Best practices encourage the use of two drugs,
mifepristone and Cytotec, in combination. The former is not widely
available in Armenia due to its higher cost, and, because treatment
with Cytotec is less effective, women are often forced to have a
surgical abortion after suffering complications. A midwife who works
in one of villages told me that she didn't believe that the drug was
effective at all due to her experience treating women who had misused
it.
I sat down with Lilit again. She told me that she was two months
pregnant. She had actually been pregnant at our previous session but
wasn't aware at the timet. She had two abortions when her children
were young. Shortly after having her second abortion, she decided to
have an intra-uterine device inserted.
According to the 2010 Armenia Demographic and Health Survey, it is
estimated that 3 in 10 pregnancies in Armenia end in abortion, though
this figure is likely underestimated.
Birth spacing, along with socioeconomic conditions, are tied as the
second most common reasons women report having abortions. The most
common is the desire not to have any more children. These statistics
highlight the dramatic unmet need for family planning. However, Lilit
is representative of many of the women with whom I'm spoken who have
used or have thought about using an intra-uterine device, which is
growing in acceptance as a method of fertility control. Considering
that women are limited in terms of the affordability, availability,
and accessibility of contraceptives, as well as their aversion to
certain contraceptives, the intra-uterine device poses as a potential
gold mine in these villages.
After five years had passed, Lilit decided to have the intra-uterine
device removed. Her two children had already grown up quite a bit and
her financial condition was relatively stable, so she was ready to
have more children. Halfway through our interview, the topic of
sex-selective abortions came up. I asked her whether or not the sex
of the fetus was important to her, to which she giggled nervously and
simply responded, `Yes'.
Many women in the villages of Armenia have told me that they must have
a son. I hear over and over again the phrase, `I have two girls; the
next one must be a boy.' Some women say that they want one boy and
one girl. Others say that they will keep trying (and often keep
having abortions) until they have a boy.
One woman even expressed to me that she was so fearful of the prospect
of having another sex-selective abortion that she preferred not having
any more children at all, even though she had originally planned to
have a bigger family and wanted a son.
In a study carried out by the
UNFPA(http://unfpa.am/en/unfpa-in-armenia), survey results show that
families primarily choose sex-selective abortions because sons
continue the family lineage, are inheritors of property, and provide
financial support. In simplified terms, this means that the roles men
play in Armenian society dictate their inherent value for families, at
least families that remain traditional.
Now, before you make any judgments about Armenian women who choose
sex-selection, let me propose this scenario to you.
Imagine that you are a twenty-seven year old woman living in a rural
village. You've already had two children. One is seven years old and
the other is five. Now that they're old enough to go to school, you
help out your family by growing fruits and vegetables and making
lavash to sell.
Your body constantly aches. You have a fairly good relationship with
your mother-in-law, but she's getting older and all of the household
chores rest on your shoulders. You use family planning sometimes, but
not all the time. It's more or less up to your husband and you don't
challenge him, because you think that whatever works for him, works
fine for you. You find out that you're pregnant.
Meanwhile your husband has left the country to work as a seasonal
migrant, and you're left alone with two children to feed, clothe, and
nurture; work in the field; a house to clean; and your elderly in-laws
who depend on you. You can't imagine raising another child, at least
not now. But you have two daughters and you know that it's really
important to your family to have a son. They talk about it around you
all the time. You think that perhaps, if you have a son, at least
he'll stay in the home with you and his wife, your daughter-in-law,
will help you manage. Your daughters will get married and move out of
the village when they reach the age of 18 or 20. Maybe you'll see
them once in a while, but they'll be busy with their own families.
Maybe, when you have a daughter-in-law, you won't be as overburdened
with work. You'll have security, which means that you'llnever end up
in a dreaded old age home with no loved ones, no running water, and an
air of hopelessness... The `choice' becomes rather simple, doesn't it?
But lets get back to Lilit. Her case was a little different. She
already had one boy and one girl, but was intent on having a second
male child. She said that she wanted her son to have a playmate, a
brother with whom he could share everything.
She said that it was important for her daughter to have a sister as
well. Ideally, she would have two boys and two girls, but the sex of
the fourth child wasn't as important. It was clear to methat she
didn't want to get too attached to her pregnancy until she knew the
sex. She said that the only pressure she felt came from herself, but
it was clear to me that she wanted to fulfill her family's wishes.
After all, her mother-in-law had given birth to two boys and two
girls, and her entire family was rooting for a boy.What could I say?
She was determined to have another son, despite everything I had told
her about the risks of having a late-term abortion and despite the
fact that she already had one son. I thanked her for her time and
accompanied her out of the room. Afterwards, I met with her
sister-in-law and encouraged her to immediately get checked-up at the
nearby hospital. She had been suffering from complications from using
Cytotec for two months by the time we met.
A month later, I bumped into the two sisters at the hospital. I
recognized Lilit's bright-colored coat, her pale pink lipstick, and
that winning smile of hers. I turned to her sister-in-law and asked
if everything was fine with her health. She giggled nervously and
said that she didn't see a doctor because, soon after our session, all
of her symptoms went away.
I tried to convince her that she would need to get checked up in order
to ensure that she had a complete abortion, that she didn't have an
infection, or worse... but she brushed me off. She felt fine. Why
should she see a doctor? Then it suddenly occurred to me why they
were at the hospital. I had seen Lilit when she was two months
pregnant. Now, a month later, it was the beginning of her second
trimester, and she was there to check the sex of the fetus. I looked
over at her. looked anxious. I make a quick remark about reconsidering
the decision, to which she smiled and nodded. I had to get back to
work, but Lilit remained on my mind. As soon as I had the chance, I
rushed downstairs to the sonogram room to find her, but she had
already left.
Fast-forward another month. I was back in the village health decided
to sit in on a health education session for pregnant mothers. There
was Lilit again, squeezed in between ten or so other women who had
come to participate. We made eye contact and greeted one another. I
didn't ask her whether she was having a boy or a girl. I was pretty
sure that I knew the answer and didn't want to prod. Nevertheless, I
was happy for her. At one point during the session, the topic of
sonograms arose. The doctor noted that sonograms are never completely
reliable in determining the sex of the fetus, even after several weeks
of gestation. I looked over at Lilit. I could tell that she was
trying to hide any signs of anxiety. It was evident that she was
thinking,what if?
Whereas I empathize with Lilit, I envision a different what if. What
if one day the sex of the fetus doesn't matter.What if the estimated
1,400 girls, who, according to the UNFPA are not being born each year,
have the chance to exist? What will it take to get to that point?
Well, I believe that a number of factors are simultaneously needed to
move past sex-selection. There is no easy fix. Though many women have
told me that sons are important for ensuring stability for aging
parents and for continuing the family line, others have told me that
the importance given to male children is simply an Armenian
phenomenon, a practice that is highly engrained in society and one
which they struggle to describe in a meaningful way.
What if medical abortion was more controlled? What if best practices
were used? What if all women were educated about the risks of taking
abortion into their own hands?
I'm convinced that we need a three-pronged approach to tackle the
abortion issue - one that combines large-scale education campaigns
with better affordability, accessibility, and availability of
contraceptives and initiatives that empower women and help them
support their families.
Inevitably, providing women with greater opportunities will raise
their morale and give their families greater financial means, which
will enable them to provide for their existing children and consider
having a larger family. (Most women in Armenia will tell you that
they have fewer children than they desire due to current economic
conditions.)
Logically, the economic component in and of itself will help reduce
the number of abortions, sex selection included. If a woman chooses
to have a larger family, that means fewer abortions. It also means
that the likelihood of having both male and female offspring will be
greater.
But economics aside, lets consider the human component. Women will be
more knowledgeable and have greater choice when it comes to having
children and using contraception.They will have the opportunity to
envision a greater role for themselves in society. And girls will be
raised in a society that finds greater value in them.
The math is pretty simple. More investment in the health and
wellbeing of women and girls means a greater future for them and for
their families. What if.
Ani Jilozian
Fulbright Research Fellow
Masters of Public Health Student
http://hetq.am/eng/articles/24468/the-story-of-two-sisters-a-perspective-on-the-abortion-issue-in-armenia.html
From: A. Papazian