AIWA supports a midwife in Armenia

In 2009, AIWA partnered with the Children of Armenia Fund (COAF) to support the work of Martha Boudakian, an Armenian American midwife who was living in Armenia. Her work in villages in the west of Armenia, performing clinical care and giving patient education and classes for midwives, was funded for two months by AIWA.

Following is a brief report on her experiences which Martha shared with COAF and AIWA at the end of 2009:

My family moved to Armenia in the spring of 2006 with my partner, Vincent Lima, editor of the Armenian Reporter. We have two young daughters; Noor 8 years old, and Arev 4 years old. It was a fortuitous situation because when Vincent was offered this position I was still on maternity leave; it made the transition easier for us.

I’m a Certified Nurse Midwife; in the States my practice includes giving well-woman, prenatal, and post partum care, and of course I attend births. I knew that I wanted to practice midwifery in some way during our stay in Armenia, but I needed to figure out an appropriate way to do so. Shortly after our arrival I started to teach classes on different topics in women's health and do independent consulting with a variety of organizations and my practice has evolved over time.

One of my strongest connections in Armenia is with the Women's Resource Center in Yerevan. It's a multi-issue feminist center that started at Yerevan State University, but has since moved away from the university and broadened its base and focus. It's been really gratifying to see a group of young feminist activists take charge of the center and in the process explore and define a contemporary Armenian feminism.

At the women’s center, I teach classes, facilitate workshops for a program called "My Body, My Rights," and serve as a consultant for the staff. Last year I participated in a special outreach project they coordinated in some Yezidi villages. Together we did human rights and health education, as well as providing some basic clinical care.

Some women at the center expressed a need for comprehensive information about pregnancy and childbirth, so I designed a 10-week pregnancy and childbirth education course that is offered there several times a year. I wanted to create a comfortable and interactive forum in which women can learn about pregnancy, childbirth, and the post partum experience. One of the course’s main objectives is for the women to be able to make informed choices about their prenatal care and childbirth. I’ve trained one of the staff members at the center and she will continue to teach the course after I leave Armenia.

As much as I have enjoyed my work in Yerevan, I also wanted to work in rural areas of the country. One evening in the spring of 2008, I was fortunate to meet the director of Children of Armenia Fund (COAF) at a dinner party. I asked her if there would be any way for me to work with COAF; she responded very positively, we met a few days later, and decided to give collaboration a try. She really took a leap of faith in agreeing to take on a midwife, as it was something new for the organization. None of the other health care staff knew what to expect of me. After one or two closely supervised visits to the villages, I arrived for work one morning and I was told, “You’ll be seeing patients by yourself today.” I’m grateful for the vote of confidence and I’m delighted to have the opportunity to provide care for women in rural Armenia.

The families in COAF-sponsored villages have a traditional lifestyle. Women marry early (approx. 16 – 21 years), and usually move in with their husbands’ families. The young woman is then placed under the tutelage and surveillance of her mother-in-law. Pregnancy is expected immediately following the marriage.

People in these villages, as in much of rural Armenia, tend to use a lot from the natural world around them and from their own gardens. Homemade herbal teas, and use of wild plants is common and the women seem to know a lot about appropriate use both for healing and for maintenance of health.

On the days I go to COAF’s villages, I divide my time between clinical care, patient education, and classes for the midwives and nurses. The midwives with whom I work in COAF-sponsored health facilities do an excellent job providing prenatal care. It’s been an honor and pleasure to spend time with them. My role is to provide collegial support and to teach a few new skills in line with their scope of practice. They've observed me teaching pregnancy and childbirth classes to their clients. The teaching style in Armenia tends to be very formal and my classes, though organized, are more casual and interactive. At first, I think they didn't quite know what to think of me. Then I decided to break the ice by demonstrating exercises for pregnancy. Now we all do them together during the classes and have a great deal of fun in the process. And they're all very patient with my Armenian which is functional, but far from perfect.

One problem is access to basic gynecological services. The only gynecologist in the district is male and is some distance from most of the villages. Seeking care from him challenges the modesty of many women and travel to that clinic can be a problem. While some midwives already were able to address and treat basic gynecologic problems, others were not. As a result, many women choose to ignore their gynecologic problems. When I ask how long a woman has been experiencing a particular problem, she’ll often answer that it’s been going on for several months, and sometimes longer. I’ve been teaching some of the midwives how to assess, treat, and follow up with basic gynecologic complaints in their own health facilities. It’s been really useful for them to be able to provide this care in a timely and culturally acceptable manner.

The midwives occasionally gather the pregnant women in their villages for group classes called “Schools of Motherhood,” and I’ve encouraged them also to include more education in their individual patient visits. For example, modern methods of contraception are not common in this region and many women still use abortion as a family planning method. Moreover I’ve found that few women in the villages have even a basic understanding of fertility. Ironically in each clinic, there is a beautiful family planning poster in Armenian prominently displayed, but with one exception none of the midwives use it as a tool for family planning counseling. Some of the midwives have begun to counsel women in their reproductive years about available family planning methods, including a discussion of cost, risks, and benefits, and basic education about the menstrual cycle and fertility.

To further illustrate the point, recently I was giving a workshop on fertility and family planning to the midwife and nurses in one village. Raucous laughter and racy comments filled the room when I performed a condom demonstration on my fingers. At that moment the doctor came out of her office to see what all the fuss was about. She was completely shocked and asked, “what is THIS?” One of the nurses said, “Dear Doctor, it’s a prophylactic.” The doctor responded, “I’ve never seen one of those in my life!”

One of the biggest frustrations for me is the lack of patient privacy and confidentiality. Although I knew that privacy is not especially important in Armenian villages, nonetheless I was horrified during my first days giving care that a woman’s mother-in-law, other members of her husband’s family, or even the neighbors who happened to be in the clinic, would wander into the exam room while I was performing a pelvic exam.

Moreover in the middle of a consultation with one person, it’s not uncommon for other patients to enter the exam room and start telling me their health care problems, seemingly oblivious to the fact that there’s another client already there. Some have seemed offended that I’ve politely asked them to wait in the lobby until it’s their turn. This habit was especially surprising to me given the high value placed on female modesty. Shortly thereafter, I started to lock the door whenever possible, which led to some altercations with irate mothers-in-law.            

One may argue that I’m inappropriately imposing my own agenda on the Armenian health system. However, I’m comfortable in suggesting the practice of protecting patient privacy and confidentiality both because of its international recognition as a right and because I’ve found that the women are considerably more open about describing their problems and history when alone or with a person of their choice in the exam room.

I consider myself really lucky to have had the chance to work in COAF-sponsored villages and to work with both the amazing health care team from COAF and the providers in the clinics themselves. They've given me a precious opportunity to see how to give good quality care with simple and limited resources and to how to keep a positive outlook and good sense of humor even in difficult circumstances.

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