The study of international experience in prevention of gender-biased sex selection shows that application of restrictions on sex selection and abortions within the national policy and legal regulation is hardly effective. Moreover, usually such restrictions target mainly and primarily women and healthcare providers; as a result, the burden of the problem is largely put on their shoulders, whereas the causes of the problem and the responsibility for the solution rest with the entire society, its culture and stereotypes. Therefore, it is not surprising that the most effective measures and tools are those targeting the society and its values. First of all, such measures imply informing the public at large, including pregnant women, their husbands and other family members, relatives and different social groups about gender-biased sex selection, its causes and harmful consequences for the society, family and an individual, as well as of reproductive rights and ethical issues of applying reproductive technologies.

Within the healthcare sector, such a toolkit requires consistent application of relevant evidence, data and analysis in awareness-raising activities. However, no matter how effective such tools are in theory, their successful application in healthcare is impossible without the knowledge and skills required for awareness and counseling among medical practitioners, service providers and healthcare organizers. In addition, a consolidated opinion of the professional community on reproductive health services related to fetal sex selection, including ethical issues of assisted reproductive services, is also prioritized.

Equity in appreciation, awareness raising and counseling: a new arsenal for a new challenge

A number of laws and by-laws should include provisions to ensure equal appreciation of girl and boy children in state programs. Hence, relevant provisions should be stipulated in the RA Law on the Rights of the Child (Article 34), the gender policy and combat against gender-based violence, the Strategies for 2016-2020 on Child and Adolescent Health and Development, and the medium-term and annual action plans and measures for their implementation.

It is also necessary to stipulate provisions on activities aimed at raising awareness on equal appreciation of girl children as compared to boy children in the Standards for Outpatient Obstetrician and Gynecological Medical Aid and Services Provision within State-Guaranteed Free Medical Aid and Services. Such stipulation is essential for healthcare providers mentioned, particularly in antenatal clinics (cabinets), health centers, rural medical stations and outpatient clinics, and first-aid-obstetrics stations. This should be included within the scope of the organization of the antenatal care of pregnant women by assistance of obstetrician-gynecologist, midwife (or nurse) and the family doctor; in the scope of social and psychological assistance; as well as within the list of activities to prevent unwanted pregnancies, sexually transmitted diseases, precancerous and cancerous diseases of reproductive organs.

Appreciation of girl children should be included in the agenda of preventive and counseling visits of healthcare providers as prescribed in the National Standard for Organizing Pre-conception Care, Preparation for Pregnancy and Maintenance of Health. It is necessary to include identification of preference for the sex of the child on the part of the woman or the couple, and discussion of the issue of equal valuing of children of both sexes with the women/couples showing such preference, in the activities of pre-conception care services.

A number of laws and by-laws should stipulate provisions on offering information and counseling on gender-biased sex selection, its consequences and prevention of such practices. Hence, the RA Law on Medical Care and Services to the Population (Article 9) should include a provision on extending the right to information for minors. The quantitative and qualitative standards for the provided medical services should also include awareness-raising and counseling. In addition, healthcare and service providers should be compelled to find out the causes of sex-selective abortion, carry out explanatory activities with the woman, her husband and family members and provide counseling aimed at possible change of the decision to make an abortion within the "waiting period" (Article 19). The RA Law on Human Reproductive Health and Reproductive Rights should also include the right of adolescents to receive information on gender-biased sex selection, its consequences, and prevention of such practices in a friendly and confidential manner (Article 5).

The Action Plan of the RA Ministry of Health, aimed at ensuring national security, particularly, its measures for maintenance of reproductive (maternal and child) health should include awareness raising activities targeting the issues mentioned above.

The documents/strategies defining the public policy for maternal and child health maintenance should also ensure provision and accessibility of information on the consequences of the gender-biased sex selection and its prevention. Such information should be included in the scope of activities aimed at improving the health of children and adolescents; preventing violence against children; encouraging healthy lifestyle among adolescents, and within their sexual education and other healthcare education programs. Such efforts should be included also in targeted programs for improving maternal and reproductive health, overcoming challenges to safe maternity, improving women's reproductive health, preventing and reducing unwanted pregnancies and secondary infertility. Finally, such information should be part of the introduction of a system for socio-psychological and physical preparation of pregnant women and within healthcare programs to prevent discrimination and violence against women. The Program of the new mid-term National Strategy on Child and Adolescent Health and Development should set out targets and activities aimed at raising awareness on the equal rights and equal opportunities of women and men, girls and boys.

The annual targeted healthcare programs, particularly the National Program on Reproductive Health Improvement should include activities aimed at raising awareness and improving knowledge among adolescents on gender-biased sex selection, its consequences and prevention of such practices. The Program should also include activities aimed at discussion of sex-selective abortions as a type of violence, awareness raising and improvement of education. Awareness-raising activities should be also planned within the services provided under the Program on Social and Psychological Assistance for Pregnant Women and Physical Preparation for Childbirth ("Mother's School"), and within measures aimed at prevention of unwanted pregnancies and reduction of abortions.

In general, counseling and awareness-raising campaigns on the consequences and prevention of gender-biased sex selection should be planned within the Standards for Outpatient Obstetrician and Gynecological Medical Aid and Service Provision within State-Guaranteed Free Medical Aid and Services mentioned above, including in the primary health facilities; the list of obstetric and gynecological medical aid and service; the scope of organizing antenatal care of pregnant women; the list of activities to prevent unwanted pregnancies, sexually transmitted diseases, precancerous and cancerous diseases of reproductive organs; in the scope of activities of family doctors, and obstetrician-gynecologists, and in the series of campaigns aimed at improving the health knowledge of the public. Similar provisions on counseling should also be set out in the Standard for Organizing Obstetric and Gynecological Inpatient Medical Aid and Service within State-Guaranteed Free Medical Aid and Services, including in the scope of the state-guaranteed free inpatient obstetric and gynecological aid. To secure funding for these provisions within the Standards, the Concept for Funding State-Guaranteed Free and Preferential Medical Aid and Services and the Timetable for its Actions should include provisions on incorporating issues related to emotional and psychological counseling of pregnant women in the draft guidance under development (Paragraph 23). Furthermore, the state-guaranteed free medical aid and service fees should reflect the issues of estimating and including the costs of psychological counseling provided to pregnant women for prevention of sex-selective abortions.

The Clinical Standards for Organizing and Providing Medical Care in Case of Abortion should include within the key public awareness messages the circumstances under which abortion is not encouraged or is prohibited, particularly on the basis of the sex of the fetus. The messages should be developed using the data from the existing studies and analyses.

The National Standard for Organizing Pre-conception Care, Preparation for Pregnancy and Maintenance of Health should include a provision on considering gender-biased sex selection as a risk, and initiating a relevant preventive intervention. The agenda of preventive and counseling visits of healthcare providers should also include a compulsory discussion of the issue of gender-biased sex selection with the couple.

The relevant provisions on awareness raising and counseling services for pregnant women, their husbands and their family members and relatives should also be prescribed in a series of practical guides, including indications and performance procedure of Stimulation and Inducement of Childbirth and Medical Abortion, as well as in the Procedures for Practices of Improved Pre-conception Care and Antenatal Surveillance over Pregnant Women and Early Detection of Fetal Development Defects. In particular, the list of topics on pre-conception care to be discussed during the counseling of couples and persons planning pregnancy should also include issues related to the consequences and prevention of gender-biased sex selection. Identification of risks of woman’s reproductive intentions and prevention of abortions should also cover issues of consequences and prevention of gender-biased sex selection, and thus it is necessary to make relevant changes in a number of forms (e.g. Consent Form, List of Pre-Conception Care Services Actions, Individual Pregnancy Preparation Checklists for women, etc.). If necessary, an opportunity should also be provided for having a talk with the woman’s husband and other family members with the woman's consent.

New sources of evidence and data in healthcare

Effective development of policies to prevent gender-biased sex selection and of awareness raising campaigns for various target groups largely depends on evidence and data describing the phenomenon, its causes and consequences. To possess such evidence and data, collection of statistical data and evidence should be a legal requirement, and the monitoring indicators of public policy strategies and respective action plans should be disaggregated by gender. Hence, the new National Strategy for Child and Adolescent Health and Development should include analytical and statistical data on awareness among adolescents on sex selective abortions, their consequences, dissemination of information on sex selective abortions. Disaggregated data for girls and boys on some monitoring indicators should be presented as well.

The national studies on domestic violence planned within the National Program for Reproductive Health Improvement should also include issues on gender-biased sex selection. The Procedure and Conditions for Abortions should prescribe compulsory analysis of statistical data that will make it possible to identify abortions performed for medical and social reasons and review the medico-social indications for abortion as necessary.

Organizational and methodological support: new knowledge and skills

The improvement of the quality of medical care in terms of organizational and methodological activities requires particularly including within the list of guidelines prescribed under the annual targeted healthcare public programs, inter alia the development and introduction of counseling by health providers to prevent gender-biased sex selection. The issues related to the training of medical personnel providing healthcare, improvement of the knowledge evaluation system and review of curricula within the new National Strategy for Maternal and Child Health Maintenance should also cover issues related to the consequences and prevention of gender-biased sex selection.

National Standard for Organizing Pre-conception Care, Preparation for Pregnancy and Maintenance of Health should incorporate a relevant training module on prevention of gender-biased sex selection within the training course for all the service providers (obstetrician-gynecologists, family doctors, midwives) involved in pre-conception care services. Within the National Program on Reproductive Health Improvement, the pre- and post-diploma training programs for medical students, residents, obstetrician-gynecologists, midwives, ultrasound specialists and family doctors/nurses engaged in prenatal care and surveillance should be reviewed and include training modules aimed at development of effective counseling skills, prevention and rejection of abortions and their complications and health consequences. In addition, modules for emotional and psychological counseling should be developed aimed at prevention of abortions and particularly sex selective abortions.

Overall, the Strategy for Development of Human Resources in Healthcare Sector should provide for development and introduction of a mechanism to exclude gender-biased sex selection in supervisory and authorization granting procedures of medical activities. The functions of professional associations engaged in planning, development and management of healthcare human resources should also include issues on coordinating awareness raising activities and holding trainings on gender-biased sex selection.

Seminars on gender-biased sex selection and sex selective abortions, as well as medical ethics issues caused by this challenge should be held with the members of the Ethics Committee under the RA Minister of Health. In addition, the public and patients should be informed on the activities, roles and responsibilties of the Committee by attracting the attention of the society and medical service providers on the necessity of observing the medical ethics rules concerning gender-biased sex selection.

---

The paper is elaborated based on the analysis of Armenian and international practices of sex selection and relevant policies to address the issue, and the opinions of independent analysts, government officials, and representatives of international organizations who participated in working meetings and round tables, organised in 2015 – 2016 within the framework of the project “Combating Gender-Biased Sex Selection in Armenia”, funded by the European Union.