Why are pregnant women ignoring doctors in Azerbaijan?

Esmira Javadova

Azerbaijan has the highest infant mortality rate in Europe, due in part to a lack of sex education for girls, according to health experts.

The infant mortality rate has improved over the past decade. But Azerbaijani doctors and other health experts warn a culture that restricts girls’ education about sex means women are ill prepared for pregnancies and unlikely to seek vital prenatal care. 

In the case of 34-year-old Baku resident Nazli (not her real name), a fatal combination of poverty and ignorance resulted in the death of two children. She nearly lost a third because she did not go to the doctor during her pregnancy.  

“She gave birth seven times. Two children were stillborn. The rest are growing up, thank god. But she never went to a doctor during pregnancy, or after the birth,” notes her mother, Latifa Allahverdiyeva. 

Nazli says she always meant to see a doctor, but never quite found the time to do so. In her most recent pregnancy, she thought she still had a month to go when labor started.

“I heard the heartbreaking cries of children at a neighbor's home. I went to see what was going on,” recalls her neighbor, Khayala.

“Oh my god, I will never forget that scene ... In the middle of the room, a woman was lying in a pool of blood, unconscious, with four children crying, ‘Mother, don’t die, Mother’.” 

It was Nazli's fifth pregnancy. When Khayala saw the blood, she thought she was dead. An emergency cesarean section saved Nazli and her baby. But not all women are so fortunate. 

Azerbaijan had the highest infant mortality rate in Europe in 2018, according to UNICEF. In that year, there were 147 infant deaths out of 13,898 registered births.  

While some health experts have said official statistics underreport the problem, Baku-based Republican Perinatal Center notes that, based on the current population, “maternal mortality and infant mortality have declined dramatically in the perinatal period.”

The drop has been credited in part to government programs, like the Ministry of Health's pregnancy portal. The portal (www.hip.az) provides information about pregnancy, including the importance of regular check-ups and other issues.

This year the government also announced a sex education curriculum for schools around the country, EurasiaNet.org reported. The program, a first for the country since the end of the Soviet Union, has already been piloted for 60,000 seventh and ninth grade students. 

The school-age program could make a real difference, according to health specialists, who fear that women around the country are putting themselves and their babies at risk due to a lack of education and information.

Ellada says girls were not offered sex education at schools when she was younger and her mother never told her about the menstrual cycle or pregnancy. Now Ellada says she is trying to educate her daughter so she will be better informed about her health.

Services at state-owned women's consultancies are free. However, Dr. Tarana Abbasova notes that even when clinics reach out to women, few come for consultations.

“Harmful processes that start during pregnancy affect the birth and then medicine also fails to save the baby,” Dr. Abbasova, a gynecologist, says, noting that the lack of proper medical treatment is the main cause of mothers and infants dying during pregnancy in Azerbaijan.

She recalls efforts by the clinic to bring them in for lectures and consultations, but she says the same people always attend. Others throw the brochures away and ignore calls to see gynecologists before and during pregnancies.

Ellada (not her real name) never visited a doctor during her pregnancies. She gave birth at home.

When I was at school, we had a class called "Human", but teachers skipped those chapters, telling the girls ‘please read those chapters at home.’ But they did not explain what it is. I was reading, but I couldn't understand anything,” she says.

Her mother also never taught her about sex or even about menstrual cycle– Ellada recalls her fear when she got her first period.

“I remember how I panicked when got my first period. A neighbor girl calmed me down, saying everything was okay. My mom never told me what to expect. Now I’m trying to be open with my daughter and tell her what will happen when she gets her period," Ellada says.

“There are no proper classes even for today's students. My daughter says that when the teacher speaks about such topics, the children -- especially boys --laugh. But sometimes people from some organizations come to schools and give some quick educational sessions for teenage girls to learn about menstruation, or give them pads.”

After two successful pregnancies and home births, Ellada finally sought professional medical treatment after she was unable to get pregnant a third time. The experience has been problematic: the medication and treatment have caused more health problems, she says.

The medicine the doctors prescribed Ellada triggered a severe allergic reaction. Health specialists worry that a legacy of poor quality -- and expensive -- medical treatment is making it harder to convince women that they need to see doctors before, during and after pregnancies.

Ellada has spent her life, including two pregnancies, depending on folk medicine and her own intuition to care for her body. One homemade treatment she uses is a brew of dried chamomile, mint and thyme as a cleansing enema for her vagina. “It is a natural and traditional recipe, so I do it regularly,” she says.

Ellada says the gynecologists she has visited have given her contradictory diagnoses, including some who simply recommended that she lose weight.

Ellada notes that she first visited a gynecologist when she struggled to get pregnant again. But the experience has been expensive, painful and largely unsuccessful.  

“Some doctors said something is wrong with my uterus. Different doctors told me that I have to lose weight. I don’t know… every doctor says different things,” she says.

One treatment resulted in her period continuing for 40 days.

“I was stressed and ashamed that it didn’t end. The doctors told me not to worry and that it would pass, but it never stopped. I went to a different doctor by recommendation of some relatives. That doctor said there should be womb scraping. And they gave me antibiotics.”

But that made everything worse. Ellada had an allergic reaction, causing her entire body to swell. Now doctors have prescribed another treatment, but she does not have time to pursue it.

Patients wait at a clinic for a doctor to perform an abortion. The government’s plan to introduce sex education as part of the public school curriculum is part of a larger effort to improve the infant mortality rate and reduce the number of gender-specific abortions in the country.

Azer Mehtiyev, an economist and chair of the Center for Economic Initiatives, says that the current health system in Azerbaijan is failing its women by not providing affordable, quality service.

While medical treatment is nominally free at state-run clinics, in reality patients are asked for bribes and face other expenses. In addition, there is a low level of trust in the doctors. 

“It is well known that pregnant women, like other patients, are often unable to approach physicians because of financial difficulties,” he says.

“It is necessary to regulate physicians, including the professionalism of the staff, the quality of services, salaries and other issues. A patient goes to the doctor, the doctor orders many – unnecessary – tests and prescribes medications that are not needed. The patient does not know if these tests and medications are necessary or not... Instead, women walk out of state health institutions, which are free only on paper, and never enter again.”

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