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