Yerevan 2016 The public inquiry has been conducted within the framework of the United Nations Population Fund Strengthening of Sexual and Repro- ductive Health Services project in collaboration with Staff of the Hu- man Rights Defender of the RA. Authors: Hamlet Gasoyan, DMD, MPH, CPH Roza Babayan Shant Abou Cham Samvel Mkhitaryan, MPH, M.S.C. The opinions expressed in this report are solely of the authors and do not necessarily reflect those of the United Nations Population Fund. © United Nations Population Fund, Armenia 2016 | CONTENTS List of Abbreviations . 5 Executive Summary . 6 1. Maternal Health Care to Ensure Safe Pregnancy and Childbirth . 6 2. Access to Family Planning: Access to Contraceptive Information and Service . 7 3. Abortion and Post-abortion Care . 8 4. Adolescents Sexual and Reproductive Health Rights including Comprehensive Sexuality Education . 9 1. Introduction . 11 2. Methodology . 14 2.1. Conceptual framework . .14 2.2. Overarching Methodology . 15 2.3. Study design and approach . .15 2.4. Study Participants . 15 2.5. Study setting and sampling . 16 2.6. Interview Guide development . 16 2.7. Data collection . .17 2.8. Data management and analysis . .17 2.9. Study rigor . 17 2.10. Ethical considerations . 18 2.11. Implementation challenges . .18 3. Legal Framework. 20 4. Maternal Health Care to Ensure Safe Pregnancy and Childbirth . 23 4.1. Trends in Maternal Health Care . .24 4.2. The Status of Maternal Health Rights in Armenia . .25 4.3. The Legal and Policy Framework. 33 4.4. Conclusions . 35 4.5. Recommendations . 36 | 3 5. Access to Family Planning: Access to Contraceptive Information and Service . 39 5.1. Trends in family planning . 40 5.2. Barriers to accessing Comprehensive Family Planning . 41 5.3. Legal and Policy Frameworks on Family Planning . 51 5.4. Conclusions . 59 5.5. Recommendations . 60 6. Abortion and post Abortion Care . 62 6.1. Legal framework of abortion services in the Republic of Armenia . 63 6.2. Trends in Abortion and post Abortion Care and Issues. 64 6.3. Access to Family Planning Information and Services, and Modern Contraceptives. 67 6.4. Drug Induced Abortions and Unsafe Abortions . 68 6.5. Pre-Abortion Counseling . 70 6.6. Post-Abortion Care . 71 6.7. Human Rights Education and Reproductive Health Care. .72 6.8. Conclusions . .73 6.9. Persons with Disabilities . .77 6.10. Sex-Selective Abortions and pre-natal Sex Determination . 79 6.11. Recommendations . 83 7. Adolescents Sexual and Reproductive Health Rights including Comprehensive Sexuality Education . 86 7.1. Situation in Armenia . 87 7.2. Laws and Regulations Pertaining to Reproductive Health and Comprehensive Sexuality Education . 89 7.3. Availability, Accessibility, Acceptability and Quality of Reproductive Health Services and Comprehensive Sexuality Education for Adolescents . 90 7.4. Conclusions . 99 7.5. Recommendations . 101 Appendices . 102 Appendix 1 . .102 Appendix 2 . 103 Appendix 3 . 105 Appendix 4 . 107 Appendix 5 . .109 4 | | LIST OF ABBREVIATIONS ADHS Armenia Demographic and Health Survey ANC Ante-natal care CAT Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment CEDAW Convention on Elimination of all forms of Discrimination against Women CRC Convention on the Rights of the Child FAPs Feldsher Midwifery posts FGD Focus Group Discussion FP planning services GoA The Government of Armenia ICESCR International Covenant on Economic, Social and Cultural Rights ICPD International Conference on Population and Development-Cairo IDI In-Depth Interview IPPF International Planned Parenthood Federation IUD Intrauterine Device MDG Millennium Development Goals MMR Maternal Mortality Ratio MOH Ministry of Health NGO nongovernmental organizations OB/GYNs Obstetritian-Gynecologists SRB skewed sex ratio at birth SRH sexual and reproductive health SRHR sexual and reproductive health and rights STI sexually transmitted infections UNECE United Nations Economic Commission for Europe UNFPA United Nations Population Fund WHO World Health Organization | 5 | EXECUTIVE SUMMARY 1. Maternal Health Care to Ensure Safe Pregnancy and Childbirth Ante-natal care, delivery assistance, emergency obstetric care, and post-natal care are among critical components required to reduce ma- ternal mortality recognized by the International Conference on Popu- lation and Development. According to the Armenian National Statistics Service, Maternal Mor- tality Ration Armenia on a 3-year average basis was 18.5 in 2014. The ratio has declined over the last decade. However, the progress is slower than it was projected by the Government of Armenia and the MDG 5A target by 2015. Our Inquiry shows that Armenia made considerable progress in ad- dressing factors behind maternal morbidity and mortality. The main achievements include introduction of the “State Maternity Certificate” offering free of charge maternal health care services, availability of skilled medical care for almost all pregnant women and appropriate re- ferral system in place, as well as favorable laws and policies. The intro- duction of continuous professional development for medical personnel provides another opportunity to continuously improve their practice and care of patients. However, there are still major issues of quality of care to be addressed. Although the Ministry of Health started to develop standards and guidelines on provision of medical services from 2011, the available clinical guidelines on maternal health care, on the national level, do not cover the whole field. Also, the current practices on defining medical malpractice and negligence are not well-defined, and leave loopholes for avoiding liability in cases of maternal morbidity and mortality. Evidence from the Inquiry also demonstrates that not all maternity cen- ters in the regions of Armenia have renovated buildings and facilities, and most importantly, updated diagnostic equipment. There is a lack of neonatologists and anesthesiologists in regions. Additionally, maternity centers generally receive the cheapest drugs, which cause concerns 6 | from the medical community. The Inquiry also reports excessive use of caesarian section operations in Armenia with an upward trend during the last five years. Our Inquiry obtained information regarding discriminatory attitudes toward HIV positive pregnant women. We also received public sub- missions indicating that accessibility of reproductive medical services is generally inadequate for women with disabilities in Armenia. The cases of violation of the patient’s right to receive consultation in pri- vate environment, not providing comprehensive information to make informed decisions and discrimination against poorer patients who use State sponsored “Maternity Certificate” vs. those who pay out of pocket is also very disturbing. 2. Access to Family Planning: Access to Contraceptive Information and Service The World Health Organization includes access to family planning ser- vices in its definition of what constitutes the universal access to SRH services. In its definition, WHO defines universal access to SRH ser- vices to include prevention, diagnosis, counseling, treatment and care services related to: ante-natal, prenatal, postpartum and newborn care; family planning services including infertility and contraception; elimination of unsafe abortions; prevention and treatment of STIs, HIV/ AIDS, cervical cancer etc. and the promotion of healthy sexuality. During the last 5 years indices of the uptake of contraceptive methods have changed. In contrast to 53.0% in 2005, ADHS 2010 results show that only 55.0% of married women (15-49 years old) use any contra- ceptive method. But in 2010 the contraceptive prevalence rate among married women has been fallen in comparison with ADHS 2000 re- sults (61.0%). During the last 10 years the rate of the uptake of tradi- tional contraceptive methods has been decreased from 38.0% in 2000 to 28.0% in 2010. Evidence gathered during the public inquiry indicates that despite of definite changes in the levels of use of family planning in the past de- cade, there are major barriers in accessing family planning services. It is notable that family planning services are not universally accessi- | 7 ble, available and affordable across the country. Evidence suggests that gender inequities, cultural norms and beliefs, lack of accurate informa- tion about FP, lack of routine supplies of FP commodities, unavailability of comprehensive FP services in lowest levels of health care system, the low level of the state budget allocations for health care, non-sufficient financing of family planning, non-sufficient accessibility of health care services and professional medical aid regarding family planning for rural population, non-sufficient level of material and technical satura- tion are some of the commonest barriers to accessing family planning services. Although the majority of the physicians who participated in our inter- views noted that many of the women who came for consultation were informed about contraceptive methods and their use, our interviews revealed that in some cases this information doesn’t come from physi- cians. Our Inquiry revealed that long distances between their homes and the reproductive health service centers are a serious problem for obtain- ing family planning services. Moreover, it is easier for citizens with education and enough financial resources to obtain modern contra- ception information and services than for women who live in villages in poverty or with little family income. The inquiry