Illustration of identical women with linked arms, and a doctor holding up an X-Ray over one woman's chest.

Ladies First

Women’s health is the best prescription for national health


Film director Seda Grigoryan recalls watching a broadcast of the Academy of Motion Picture Arts and Science Awards as they announced the best short documentary, “Period. End of Sentence”—a movie following a group of women in Hapur, India working to create accessible menstrual products and equity to local communities. What struck Grigoryan was the Armenian translation of the title to “Punctuation. The End of The Sentence” in addition to the Armenian program’s hosts dodging the topic of menstrual cycles, the subject matter of the Oscar-winning film. “All three presenters likely held their breaths, because they couldn’t say that shameful, disgraceful word: period,” Grigoryan wrote in a viral Facebook post. This instance pointed to a larger issue in Armenian media and culture: discourse around menstrual cycles, and women’s health in general, is often considered unmentionable or shameful. “When the schools, TV programs, and people are silent, the dialogue around women’s health is turned into a whisper or secret,” she concluded.

Taking stock of the health and well-being of Armenia’s women goes well beyond starting this discussion. Just like other women across the world, Armenia’s female population is faced with health concerns at every stage of life—many that often go unnoticed or are put aside to care for others. From preventative screenings for breast and cervical cancers to gynecological and maternal health and wellness, Armenia has made strides to ensure resources are available to its women—yet entrenched attitudes and behaviors among women themselves are lagging behind.

I do this because I believe in the empowerment of women. We’ve done this work to help heal mothers in Armenia, because mothers are not only the pillars of the family, but their community, and their nation.

High on the list of prevalent trends are maternal mortality rates. As a result of prenatal care, the number of deaths in childbirth remains a concern for families in both urban and rural regions of Armenia. Equally critical is the alarming rate of breast and cervical cancers—among the most common cancers in Armenia, while preventative screening rates falter. Though the governmental Basic Benefit Package (BBP) covers annual Pap tests, out-of-pocket payments for non-pregnancy related health issues also account for the poor showing for preventive care. With fees for service care constituting 65% of all healthcare disbursements in the country, these examples are but the tip of the iceberg. For Armenia to become a more inclusive picture of health, an overall shift in culture is needed to prioritize routine check-ups and screenings.

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Cervical Cancer Screening by Region in Armenia
Cervical Cancer Screening by Region in Armenia
Source: HPV Information Center

 

Pioneering Institutions

Innovative facilities like the Armenian-American Wellness Center (AAWC) are spearheading the change in women’s health care. In response to the alarming incidence of breast cancer amongst Armenia’s women, it was as early as 1997 when the Armenian-American Cultural Association initiated a medical mission to Armenia with the intention of founding a Mammography Center at Yerevan State Medical University. What was envisioned to be a specialized unit grew to become a towering pillar in the field of women’s health, encompassing any and all health and wellness needs a woman might face throughout her life. “We now have ten departments, including 123 people working at the center, 64 of which are doctors,” Rita Balian, co-founder and president of the AAWC reports. Her inspiration to continue the expansion of the AAWC are the resilient mothers of Armenia. “I do this because I believe in the empowerment of women. We’ve done this work to help heal mothers in Armenia, because mothers are not only the pillars of the family, but their community, and their nation.”

Balian, alongside the late Vartkess Balian and co-founder Hranush Hakobyan, never anticipated the current size and strength of the state-of-the-art and skillfully staffed wellness center. “We started with the mammography center, interviewed and selected the best doctors, and as we continued to grow we wanted to establish resources for women with cervical cancer,” Balian begins. “We added a gynecology department for cervical screenings, but then we wanted to help women with fertility services. Then we realized we needed to include family medicine.” Today, the AAWC is the leading facility for breast cancer care and treatment. A one-stop shop for all check-ups, services, and exams, the AAWC provides radiology, diagnostic imaging, gynecological services, family medicine, endocrinological services, laboratory tests, rehabilitation, bone health exams, and even laser treatment for vascular damages and skin pigmentation. Consultations, conferences, and seminars are also provided by the center, hoping to improve education and awareness of women’s health. On average, the AAWC performs between three to eight surgeries a day and has cared for over half a million patients. To date, they’ve screened 329,521 patients for breast cancer and have detected 16,704 cases—saving 12,436 of the women and 78 of the men also screened. Also a tour de force in the field of diagnostic imaging, the AAWC ensures every woman receives a bone densitometry test to screen for osteoporosis—screening 9,812 women to date. Partnering with the United States Agency for International Development (USAID) for additional funding and grants, the AAWC continues to uphold modern care with up-to-date technology, equipment, and medical professionals—proving to be a model for women’s health in Armenia.

Breast Cancer Awareness 

Breast cancer is more common in Armenia than anywhere else in the world, and the mortality rates are almost twice as high in Armenia. Despite this startling statistic and government-sponsored enterprises, women in Armenia continue to face hurdles to obtaining precautionary screening for breast cancer. UCLA Resident Physician Razmik Ghukasyan is examining the reasons behind the lack of preventative care amongst the women of Yerevan, hoping to improve the preventable female mortality rates as a result of breast cancer. Initially, Ghukasyan hypothesized the biggest impediment would be a low estimation of effective care and a general lack of desire to receive breast cancer screenings. “Surprisingly, this was not the case in Yerevan,” he states, claiming the root of the problem lies with the lack of initiative taken by healthcare professionals.

His emerging research evaluating beliefs, attitudes, and barriers towards breast cancer and screening has reported that only 25% of women have discussed breast cancer screenings with their physicians, and half of the women studied refused to get mammograms voluntarily. Though almost half of the participants have performed self-exams, only a quarter of women interviewed in Yerevan have actually received mammograms. “Participants recognized the value of early detection and prevention and the role of mammograms, but a majority of participants did not want to voluntarily participate in screening without a physician’s recommendation,” Ghukasyan observes.

Another barrier to preventative screening is the fear of expenses linked to breast cancer. According to Ghukasyan’s study, “Overall, 80% of women expressed fear and anxiety over getting positive breast cancer results, but only 10% thought they were at risk in their lifetime.” Out-of pocket expenses for treatment should not prevent women from receiving screenings, especially when breast cancer has an incidence of 68/100,000 cases. “Interestingly enough, 25% of responders reported that they had first or second-degree blood relatives diagnosed with breast cancer, 40% of whom before the age of 40 and around 60% of those have died,” Ghukasyan notes. He poses the question, “Is the country’s healthcare system ready to handle a surge in screening and follow-up care?” To understand the scope of the resources needed to supply such services, like the volume of biopsies, breast surgeries, and specialized medicine, more research needs to be conducted. Though the current state of preemptive breast screening is a tough pill to swallow, ongoing research proves that there is still a long road ahead.

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Illustration of woman bowing on a stage with the curtains pulled back to reveal a doctor's office. The woman is also in a hospital gown.
Illustration of woman bowing on a stage with the curtains pulled back to reveal a doctor's office. The woman is also in a hospital gown.
Illustration by Peter Ryan

 

Prevention is Proven

After breast cancer, cervical cancer ranks the second most frequent cancer among women in Armenia. “Despite cervical cancer being one of the most preventable and treatable forms of cancer if detected in its early stages, it is still a striking problem in Armenia. Every year 270 women are diagnosed with cervical cancer, and almost half will die as a result,” Narine Hayrapetyan, Executive Director of Fighting Infectious Diseases in Emerging Countries (FIDEC) notes.

According to the HPV Information Centre, HPV types 16 and 18 are responsible for about 70% of all cervical cancer worldwide, and there is growing evidence of HPV being a relevant factor in other anogenital cancers in addition to head and neck cancers. They report that while cervical cancer screening strategies differ between countries, the most frequent method is cytologic evaluation, the analysis of cells under a microscope, and visual inspections. In their estimated coverage of cervical cancer screening in Armenia, the regions with the highest levels of screening are Armavir (10.1%) and Yerevan (9.9%) while regions like Aragatsotn (0.4%), Gegharkunik (2.7%), Syunik (2.9%) Tavush (5.7%), and Vayots Dzor (5.5%) ranked the lowest.

The FIDEC Armenia Foundation is at the forefront of cervical cancer prevention and reform. In early July, FIDEC hosted a panel discussion in partnership with the 5th International Medical Congress of Armenia (51MCA) to discuss the prevention of HPV. “Around 80% of people contract HPV infections at some point in their lifetime, and the global and clinical research proves that HPV vaccination prevents diseases and the risk of cervical cancers by 70 to 80%,” FIDEC declared. Dr. Daniel Stamboulian, the Argentine founder of the FIDEC Foundation and leading infectious disease specialist, also noted the positive results of HPV vaccinations in Argentina. “The HPV vaccination has been implemented for young girls and boys, and we are coordinating an epidemiological study to evaluate the prevalence of HPV infections among young women in Armenia.” Clearly, prevention is key when it comes to cervical cancer. “Vaccination against HPV, in addition to Pap screening of detectable and treatable precancerous lesions, is one of the most effective ways of preventing cervical cancer,” notes Gayane Sahakyan, Manager of the National Immunization Program. Pap smears are critical in the prevention of cervical cancer, as the collection of cells from the cervix is the first step in halting the development of such concerns. While Pap tests are covered by basic plans, they are still not routinely performed by physicians.

Nevertheless, Armenia is taking steps in the right direction to tackle cervical cancer with concentrated efforts to make the HPV vaccine and Pap screening readily available to young women. A budding program doing so is the Tavush Health Project to aid Azatamut, Khashtarak, Lusahovit, and Ditavan communities of Ijevan. Since 2011, the Tavush Project has assisted almost 200 women in preventative care and training—specifically gynecological examinations, lab diagnostics, and training for the OB/GYNs in Ijeven. They hope to provide free breast and cancer screenings to all women living in rural and peri-urban areas and more importantly, to raise awareness among women about the importance of screening and ultimately, to reduce the incidence and mortality of these cancers.

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Attitudes toward breast cancer screening in Armenia
Attitudes toward breast cancer screening in Armenia
Source: UCLA Resident Physician Razmik Ghukasyan

 

Maternal Health

According to the United Nations Popu-lation Fund of Armenia, the maternal mortality rate is about five times higher in Armenia than the European average, though cases have dropped since 2010. According to their research, the main causes were extragenital diseases (31%), obstetric bleeding (27%), hypertensive disorders (25%), abortions (3%), sepsis (8%), and other causes (6%). Dr. Sam Badalian, Urogynecologist and Chief of Women’s Health at Basset Medical Center in New York, stresses the need for specialized surgical skills. “The highest cause of maternal death, which is preventable, is postpartum hemorrhage,” says Badalian. “Every time I hear an Armenian woman died in childbirth, it kills me because the majority of those lives could have been saved with high-risk pregnancy management.”

A powerhouse in the shift in maternal care is the AGBU Hye Geen Pregnant Women Care Centers. Through partnerships with the Yerevan State University, Hye Geen has established five centers for women in Yerevan, Vanadzor, Talin, Yeghvard, and Yeghegnadzor. Founder of Hye Geen Sona Yacoubian was motivated to create the Pregnant Women’s Centers after visiting a gynecological ward of a hospital in Armenia in 1995. “When I saw young women there with all kinds of infections, unsafe abortions, malnourished and depressed—I came back to California distressed, and our community decided to mobilize and help out sisters in Armenia,” Yacoubian recollects. Seven years of fundraising and research later, the Hye Geen Committee opened the doors to the first Pregnant Women’s Center in Gyumri. Their first initiative was eradicating malnutrition in pregnant women, which caused unusually high infant mortality rates and complicated births. “The initial goal was to support a group of 20 women throughout their pregnancy by offering prenatal care, vital medical exams, personalized counseling, nutritious meals, and guidance,” Yacoubian notes. However, their attention has since shifted to focus on the UN’s Eight Millennium Development Goals (MDGs) aimed at radically reducing extreme poverty and hunger, the promotion of gender equality, the reduction of childhood mortality, and the improvement of maternal health.

Since their opening, over 5,000 babies have been safely delivered. “And you have to multiply that number twice because we take care of two lives with healthy deliveries,” Yacoubian states. Not only does Hye Geen focus on physical health and wellbeing, but they also strive to encourage female empowerment through their TV station, Hye Geen magazine, and online lectures and courses produced from their headquarters in California. Their latest initiative has partnered with Yerevan State professors to form youth groups for young brides and their families to encourage confidence-building and empowerment within a family dynamic. As Yacoubian astutely stated, “In a family, women are placed in the middle. They have their little ones, and their elderly ones to take care of. But someone has to empower her to take care of herself.” That is where Hye Geen centers come in.

Infant Feeding Factor

A healthy family starts with a healthy relationship between a mother and her newborn. Studies prove the behavior of mothers can drastically improve the health outcome of their babies, starting with breastfeeding and skin-to-skin contact—imperative to both mother and child. Though not all women have access to the support needed for this healthy balance, programs have been implemented to promote breastfeeding and improved infant health. Assistant Professor of Nutrition in Pediatrics at Columbia University Dr. Kim Hekimian is another trailblazer in women’s health in Armenia. In her quest to promote breastfeeding as the better alternative to formula, she and her team discovered that 50% of new mothers did not touch their newborns within 24 hours of birth—a critical window that impacts the mother’s milk supply production. This has been attributed to the conventional practice of allowing the mother complete rest right after the exhausting experience of labor. “What we know is that breastfeeding is optimal nutrition,” Hekimian says. “But we also know women need support to be able to exclusively breastfeed. The most important cost-effective intervention to improve breastfeeding outcomes is to have the mom and the baby have skin-to-skin contact on the chest within one hour of birth.” As a result of Hekimian’s study, the first national survey of infant nutrition practices in Armenia, a breastfeeding promotion campaign funded by the USAID, UNICEF, and the Ministry of Health tripled the breastfeeding rates and reduced post-neonatal mortality.

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Main Causes for Maternal Mortality in Armenia
Main Causes for Maternal Mortality in Armenia
Source: United Nations Population Fund in Armenia

 

The Strength of Experience

Knowledge is power when it comes to post-graduate medical schooling and quality training. “Though organizations have built structures, the structure itself does not at all ensure that there will be a quality of care going inside of it,” notes Dr. Kim Hekimian. Simply constructing new hospitals isn’t enough—transforming and building upon medical practices and addressing the systems in place are necessary to make a profound change. Hekimian stresses transfer of knowledge, consistent training, partnerships for transparent healthcare finances, and access and equitability among economic classes. “If you’re going to do a medical mission, for example, you should be measuring whether or not your mission led to a change in knowledge, a change in attitude, and then eventually any change in clinical practice, and build on that,” Hekimian advises.

Dr. Badalian is another example of an advocate pushing for quality care through capacity-building programs in Armenia. “I’ve been going to Armenia for the last 20 years to teach urogynecology in Yerevan and the Tavush region—specifically for the aging female population who face problems with prolapse incontinence, teaching students how to perform pelvic reconstructions and counter-incontinence surgeries for women.” In his study of 600 women (50 from every region), Dr. Badalian discovered that women who received pelvic floor surgeries now have even poorer complications than women who didn’t receive such surgeries. “This was the biggest surprise for all of us doing this research because this means that poor quality health care is worse than no health care,” he notes. The change, he observes, needs to start with hands-on comprehensive residency programs. “Even though the number of residents is extremely high, the numbers of deliveries and C-sections performed, for example, are very low. Residents need to be assigned according to the number of vaginal deliveries and C-section surgeries per hospital. If a hospital has 1000 deliveries, they can only have two residents, not ten.” Badalian is currently working with five other urogynecologists from Boston, Lebanon, Rhode Island, Michigan, and Moscow to prepare a curriculum for a two-year urogynecology fellowship in Armenia, modeled after a similar program he created in Ghana, Africa five years ago. He hopes to work with the Ministry of Health to teach two fellows at Yerevan Medical University and the National Institute of Health with practical experience, lectures, and rotations, gradually increasing the number of fellows per year. “It’s time for Armenia—not just to operate. Doing individual surgeries once or twice a year is not going to solve the problem. You need people. You need boots on the ground. You need education and long-term commitment and communication with existing technologies and institutions.”

It’s necessary to break this taboo so loudly that we change existing conditions. Only then will this silent discrimination that is inherited, transmitted, and embedded in our thinking, become apparent.

Future is Female

For Armenian healthcare systems to successfully service and benefit Armenia’s women, a cultural shift is needed to promote healthy conversations around women’s health and equality. This can begin with social media platforms, like the recent #SheCounts campaign launched by the UNFPA. Government leaders, influencers, and celebrities alike have taken to social media to post photos of themselves with women who have empowered them, with the hashtag #SheCounts. This campaign has been promoted by the likes of Arsen Torosyan, Minister of Health, to Ara Tadevosyan, Director of MediaMax News, to promote female empowerment. As Grigoryan emphatically noted in her post, “It’s necessary to break this taboo so loudly that we change existing conditions. Only then will this silent discrimination that is inherited, transmitted, and embedded in our thinking, become apparent.”

Banner Illustration by Peter Ryan

Originally published in the 2021-03-01​ issue of AGBU Magazine. end character

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