BackgroundArmenia has an upward trend in cesarean sections (CS); the CS rate increased from 7.2% in 2000 to 31.0% in 2017. The purpose of this study was to investigate potential factors contributing to the rapidly increasing rates of CS in Armenia and identify the actual costs of CS and vaginal birth (VB), which are different from the reimbursement rates by the Obstetric Care State Certificate Program of the Ministry of Health.MethodsThis was a partially mixed concurrent quantitative-qualitative equal status study. The research team collected qualitative data via in-depth interviews (IDI) with obstetrician-gynecologists (OBGYN) and policymakers and focus group discussions (FGD) with women. The quantitative phase of the study utilized the bottom-up cost accounting (considering only direct variable costs) from the perspective of providers, and it included self-administered provider surveys and retrospective review of mother and child hospital records. The survey questionnaire was developed based on IDIs with providers of different medical services.ResultsThe mean estimated direct variable cost per case was 35,219 AMD (94.72 USD) for VB and 80,385 AMD (216.19 USD) for CS. The ratio of mean direct variable costs for CS vs. VB was 2.28, which is higher than the government’s reimbursement ratio of 1.64. The amount of bonus payments to OBGYNs was 11 fold higher for CS than for VB indicating that OBGYNs may have significant financial motivation to perform CS without a medical necessity. The qualitative study analysis revealed that financial incentives, maternal request and lack of regulations could be contributing to increasing the CS rates. While OBGYNs did not report that higher reimbursement for CS could lead to increasing CS rates, the policymakers suggested a relationship between the high CS rate and the reimbursement mechanism. The quantitative phase of the study confirmed the policymakers’ concern.ConclusionThe study suggested an important relationship between the increasing CS rates and the current health care reimbursement system.

Background: Despite global efforts, stunting remains a public health problem in several developing countries. The prevalence of stunting among 0-to 5-year-old children in Armenia has increased from 17% in 2000 to 19% in 2010. A baseline study was conducted among preschool children in Berd, a region near the northeastern border of Armenia that has experienced intermittent military tension for over 20 years. Methods: We conducted a cross-sectional study including 594 children aged 6-month-6 years old and their caregivers in our analysis, to assess the prevalence and determinants of stunting. We calculated the anthropometric measurements and hemoglobin levels of children; analyzed children's stool and conducted a survey with children's caregivers. We employed the hierarchical logistic regression model to explore the predictors of stunting among 25-72 months old children and multivariable logistic regression models to investigate the predictors of stunting among 6-24 months old children. Individual and residence level variables were included in the models including anemia, minimum dietary diversity, mothers' height, the overall duration of breastfeeding, birthweight, child's history of diarrhea and mean socio-economic score. Results: The prevalence of stunting was significantly higher among the 6-24 months old children (13.3%) compared to the children aged 25-72 months old (7.8%). We did not find any differences in the prevalence of stunting by place of residence in either age group. The 6-24 months old children who consumed at least four food groups during the previous day (minimum dietary diversity) had 72% lower odds of being stunted (p < 0.05). Each kilogram increase in birthweight was associated with 76% lower odds of being stunted (OR = 0.24, p < 0.01). Mother's height significantly decreased the odds of stunting among the children 25-72-months old (OR = 0.86, p < 0.001). BMI was also a significant predictor of stunting among both age-groups. Conclusions: The study results highlight the significance of mother's height, birthweight, and adequate complementary feeding to reduce stunting. Further studies are needed to determine the possible association of anemia and stunting with the ongoing conflict in the region, as well as socioeconomic conditions and food insecurity in the region.

The study findings suggest that although WV nutrition interventions have shown impact, there is also a nonnutritional pathway of child stunting in rural Armenia. Thus, antistunting interventions should include sanitation and hygienic measures along with adequate perinatal care and maternal and child nutrition to further reduce childhood stunting, ensuring long-term health benefits for children not only in rural Armenia but also in rural communities in other low/middle-income countries.

Despite documented low-quality care in Armenia, surveys document high ratings of patient satisfaction with health care services. We explored reasons for high satisfaction in Armenia despite poor quality. Twenty-five women who recently delivered participated in this qualitative study through in-depth interviews. Patients avoided critiquing health care services because of personal relationships with and respect for providers and fear of losing services. Although they shared an understanding of what quality care should be, many were satisfied because their low expectations were met. Further mixed methods research may explain this dissonance. Until then, patient satisfaction measures need careful, contextual interpretations.