Late-Term Abortion for Fetal Anomaly: Vietnamese Women's Experiences

Abstract

Screening for fetal anomalies in the second trimester of pregnancy is increasingly becoming a part of antenatal care. As a consequence, more pregnant women are learning that the child they are expecting has an anomaly. This article derives from anthropological research in a hospital in Hanoi, Viet Nam, from 2003–2006 that investigated 30 women's experiences after a fetal anomaly was detected. We followed the women from the ultrasound scan through the process of deciding whether to continue their pregnancy or have an abortion. This article focuses on the 17 women who had an abortion and the support they received from health care providers. Their loss of a wanted pregnancy led to feelings of guilt, pain and sadness and fear and uncertainty about being able to have a healthy baby in the future. Two years after the abortion, most of the women had come to terms with the loss, especially those who had had a healthy child since. We recommend that the Vietnamese health care system seeks to ensure that women receive counselling and support that answers their questions about what happened and why. To do this, health care staff need additional training in fetal medicine and counselling skills and sensitisation to the social and emotional challenges that detection of fetal anomalies and second trimester abortion bring to antenatal care.

Résumé

De plus en plus souvent, le dépistage des anomalies fłtales au deuxième trimestre de grossesse fait partie des soins prénatals. Par conséquent, davantage de femmes enceintes apprennent que l'enfant qu'elles portent présente une anomalie. Cet article utilise la recherche anthropologique menée dans un hôpital de Hanoï, Viet Nam, de 2003 à 2006, sur l'expérience de 30 femmes après la détection d'une anomalie fłtale. Nous avons suivi ces femmes depuis l'échographie et tout au long du processus de décision sur la poursuite ou l'interruption de la grossesse. L'article se centre sur les 17 femmes qui ont avorté et le soutien qu'elles ont reçu des soignants. La perte d'une grossesse désirée a suscité des sentiments de culpabilité, de douleur et de tristesse, ainsi que de peur et d'incertitude sur leur capacité future d'avoir un enfant sain. Deux ans après l'avortement, la plupart des femmes avaient surmonté leur perte, particulièrement celles qui avaient depuis mis au monde un enfant en bonne santé. Nous recommandons au système de santé vietnamien de veiller à ce que ces femmes reçoivent des conseils et un soutien répondant à leurs questions sur cet événement et ses raisons. Il faut pour cela mieux former le personnel soignant à la médecine fłtale et aux compétences de conseil, et le sensibiliser aux enjeux émotionnels et sociaux que la détection des anomalies fłtales et l'avortement du deuxième trimestre supposent pour les soins prénatals.

Resumen

La detección sistemática de anomalías fetales en el segundo trimestre del embarazo es cada vez más parte de la atención antenatal. Por consiguiente, más mujeres embarazadas se enteran de que el niño que esperan tiene una anomalía. Este artículo se basa en una investigación antropológica realizada en un hospital de Hanoi, en Vietnam, desde 2003 hasta 2006, sobre las experiencias de 30 mujeres después de detectada una anomalía fetal. Seguimos a las mujeres desde el estudio de ultrasonido a lo largo del proceso de decidir si continuar su embarazo o tener un aborto. Este artículo se centra en las 17 mujeres que tuvieron un aborto y en el apoyo que recibieron de los profesionales de la salud. Su pérdida de un embarazo deseado ocasionó sentimientos de culpabilidad, dolor, tristeza, temor e inseguridad en cuanto a poder tener un bebé saludable en el futuro. Dos años después del aborto, la mayoría de las mujeres habían aceptado la pérdida, especialmente aquéllas que habían tenido un hijo saludable desde entonces. Recomendamos que el sistema de salud vietnamita procure garantizar que las mujeres reciban consejería y apoyo que conteste sus preguntas sobre qué sucedió y por qué. Para ello, el personal de salud necesita recibir más capacitación en medicina fetal y habilidades de consejería y sensibilización a los retos sociales y emocionales que implica la detección de anomalías fetales y el aborto en el segundo trimestre para la atención antenatal.

Key Words:

• second trimester abortion
• fetal anomaly
• antenatal screening
• Viet Nam

Increasing numbers of women the world over are being offered some form of screening or testing during pregnancy. Ultrasound scanning, the most low-cost of all technologies for antenatal screening, has achieved a central position in antenatal care in many countries, being used primarily for assessments of the normality and in some cultures, including Viet Nam, the sex of the fetus.^1–4 As a consequence, more women are being informed during pregnancy that their child-to-be differs from the one they had hoped to have.

Fetal anomalies are most often detected in the second or third trimester of pregnancy. Studies in Europe and North America show that termination rates after antenatal diagnosis of a malformation very widely across countries and fetal conditions.⁵ A review of 20 studies found overall termination rates of 92% for Down's syndrome, 64% for spina bifida, 84% for anencephaly, 72% for Turner syndrome and 58% for Klinefelter syndrome.⁶ Forty-five per cent of the world's countries permit abortion for fetal impairment, including 32% of developing countries and 84% of developed countries.⁷ Late termination of pregnancy for fetal abnormality is permitted on differing grounds in different countries, depending on the type of malformation, gestational age at diagnosis and abortion legislation.⁵⁷

Over the past few years, the feelings and reactions of women who undergo late-term abortion for fetal malformation have been explored in a number of studies,^8–14 mainly in western Europe. There is a lack of studies of how women living in other parts of the world cope with this experience. Moreover, most existing studies are quantitative in nature; few have investigated how support and care may be enhanced for women in this situation.

The aim of the research reported here was to investigate Vietnamese women's experiences and the decision-making process when a fetal anomaly was detected through ultrasound scanning. This article focuses on 17 women who had a late-term abortion due to a fetal malformation, describing their experiences of the pregnancy termination, the support they received from health care providers, and their feelings and reflections two years later. On the basis of our findings, we discuss issues that are important to take into account when providing support for women undergoing late-term post-diagnostic abortions.

Antenatal screening and late-term pregnancy termination in Vietnam

Viet Nam's Population Strategy for the years 2001–2010 emphasises enhancement of the “quality” of the country's population through, among other means, antenatal screening for fetal malformations.¹⁵¹⁶ During the second Indochina war, from 1961 to 1971, US aircraft sprayed large amounts of the highly toxic herbicide dioxin nicknamed Agent Orange over Viet Nam. Today, there are widespread fears among policy-makers, in research communities and in the general population that this has caused long-term health damage, including miscarriages and birth defects.¹⁷ Partly in response to these fears, technologies for antenatal screening such as ultrasound and amniocentesis are currently receiving concerted attention and support.

In Hanoi, Viet Nam's capital, ultrasound scanning has taken up a central position in antenatal care in the past 5–10 years. Scans are used for both obstetric and screening purposes and are often followed by induced abortion if a fetal malformation is detected.^3,16,18,19 Abortions are legal in Viet Nam and performed until 22 weeks of pregnancy. If an anomaly is found, there is no legal upper limit for abortion, and decisions about pregnancy termination after week 22 are made by a professional board at the hospital where the abortion would take place. Second trimester abortions are provided at central and provincial level public health facilities only.

National statistics on the number of late-term abortions for fetal malformation are not compiled annually, but hospital records where our research was conducted showed that the annual number of late-term pregnancy terminations for fetal malformations more than doubled during the period of our research: from 42 in 2003 to 102 in 2005, an increase that is likely to be related to the expanding use of antenatal ultrasound screening. In the same period, the number of deliveries rose less steeply, from 15,557 to 16,281. Whereas many hospitals in Vietnam still rely on the Kovac's method for second trimester abortions, this hospital has for about a decade used misoprostol (Cytotec) for late-term pregnancy terminations. At the time of the research, feticide was not performed and fetal autopsies were not done after late-term abortions.

Methodology

This article derives from anthropological research conducted in Vietnam's capital Hanoi from the end of 2003 to early 2006 by a research team of one Danish and ten Vietnamese researchers. The research was part of a larger project aiming to enhance research capacity in Vietnam. Throughout the research period we held bi-monthly workshops where research tools were developed and adjusted, preliminary insights discussed and analysis of data commenced.

During the initial, hospital-based part of the research, we worked in the 3D ultrasound scanning room at a major maternity hospital in Hanoi, exploring women's use of ultrasound scans. When a fetal anomaly was detected, we invited the pregnant woman and her relatives to participate in the research on a more long-term basis. Of 45 women contacted, 30 women were enrolled. Six were excluded either because the fetus had died in utero or because they lived more than 100 km from the hospital, and nine declined to take part. In 2005, we extended our sample to include another 25 women in order to substantiate our findings, but the present article is based primarily on our interactions with the initial 30 women.

We followed the 30 women closely from the ultrasound scan, through the process of deciding whether to continue the pregnancy until after the abortion or birth of the child. We accompanied the women through obstetric care at the hospital, taking detailed notes of both verbal and non-verbal interactions between patients and providers in the scanning room, the antenatal department, hospital corridors and the maternity ward where abortions take place. We also talked to each of the women in their homes at least once and most often on several occasions. If other family members, such as husbands, parents or parents-in-law, were at home, they often participated as well, at least part of the time.

Being informed of the fetal anomaly threw the women into a profound social and existential crisis, posing a number of ethical challenges for the research. We emphasised listening to their stories and being attentive to their questions and concerns rather than pursuing pre-defined research questions. Unfortunately, we were often unable to provide the women with the clear answers to their questions that they had hoped to obtain from us, but when relevant, we helped them to contact specialist medical facilities such as the National Paediatric Hospital or the genetic counselling centre at Hanoi Medical University. On their own initiative, a few of the women stayed in contact with us during the nearly three years of research; we contacted the others for a brief follow-up interview approximately two years after the abortion or birth had taken place.

Over a period of four months, we conducted daily observations and informal conversations with health staff at the maternity hospital, working mainly in the 3D ultrasound scanning room, the antenatal care department and in the department for reproductive disorders. We interviewed 14 doctors (12 obstetricians and two sonographers) and conducted a focus group discussion with doctors. Our aim was to obtain an understanding of these professionals' own perceptions of the opportunities and challenges that this new technology created for antenatal care. In order to stay open to providers' own views of their work, we did not use any pre-defined checklists during observations, and our guidelines for interviews and focus group discussion were loosely structured and used flexibly. During all components of the research we took detailed notes of social interactions and verbal exchanges, and all interviews and the focus group discussion were tape-recorded and transcribed. Analysis was on-going throughout the period of research, undertaken through detailed coding of notes and transcriptions, and resulting in the publication of a series of articles in local academic journals.^20–24

Pregnancy outcomes

Of the 30 women, 13 continued the pregnancy, while 17 opted for an abortion. Based on the ultrasound scans, the 17 women who opted for abortion were informed that their fetuses suffered from at least one of the following problems: dilatation of ventricles/hydrocephalus (6), hydrops fetalis (4), abdominal/umbilical hernia (2), anencephaly (1), abdominal anomaly (1), prune belly syndrome (1), cleft lip (1), and twins with a shared spine (1). The 13 women who carried their pregnancies to term were informed that their fetuses suffered from the following conditions: dilatation of ventricles/hydrocephalus (5), abdominal/umbilical hernia (2), anencephaly (1), abdominal anomaly (1), heart defect (2), curved arms/legs (2).

The 17 pregnancies were terminated at varying stages of gestation: two women were at 14–18 weeks, eight at 19–24 week, five at 25–30 weeks and two at 32–35 weeks. For one woman, this was the second pregnancy termination for fetal malformation, for another it was the third. We were able to contact 16 of the women again for a follow-up interview. We met 11 of them face-to-face and talked to five on the telephone. Of these 16 women, nine had become pregnant again in the intervening period. Four had given birth to a healthy child, one had a child with a minor disability, one had an induced abortion, one a miscarriage, and two were half-way through a pregnancy without complications.

Women's experiences of second trimester abortion for fetal anomalies

“Here”, the nurse says, handing Hà a white tablet. “Take this.” It is 3 April 2004. We are at the obstetric hospital, in the department for reproductive disorders. Hà has changed from her own clothes into the hospital's red-and-white flowered pyjamas. She is 28 weeks into her pregnancy and preparing to undergo an abortion, as an ultrasound scan has found abdominal hernia in the fetus. Hà swallows the pill. Then the nurse sends her with her things to room 28. She does not explain what the pill was for or what will happen next. Three days later we return to room 28. Hà is sitting upright on the woven straw mattress on her bed, looking very calm. She shares the room with six other women, some of them with their newborn infants next to them in the bed. Hà tells us about the abortion. The labour was short, but the pain was terrible, much worse than during her daughter's birth. But the worst pain, she says, was not physical but psychological:

“I felt so sorry for myself. I asked if I could give birth here, in this department, rather than in the maternity ward where other women give birth. They had their children. I gave birth too, but I had no child. When the little one came out, it gave some gasping sounds and two cries. Then they took it to another room.”

When we met her in her home two weeks later, Hà told us that this was the fifth pregnancy she had lost. Her first pregnancy went well, and when we met her she had a daughter aged seven. But her attempts to have another child had all failed: all four times, the fetus had died at about three months of pregnancy and was removed surgically. So she had felt elated to make it past the three months, hoping that this time her daughter would have a younger sibling. She described how sad she had felt when returning home from the hospital without a child:

“It took four days before the milk stopped running, and there was so much of it. I felt so sad. In the evenings, when my husband and daughter were here, I felt OK, but when I was alone I was so sad. You see, the difference between this fetus and the ones that died by themselves was that they gave up on me – but I gave up on this one. I felt it was wrong and I missed my child. But my sister consoled me, she said that according to Buddhist scriptures, I did the right thing. I spared my child from suffering.”

Hà had not seen the fetus after the abortion:

“I could feel that its intestines were outside the body, and its head was very small, but I did not dare look at it. My husband did not either. No one dared look at it, we were afraid that we would never be able to forget it, that it would leave a mental imprint on us forever. Not even the doctor dared look at it. She looked away while cutting the cord. She felt uncomfortable. She said, ‘It is such happiness to assist at the delivery of a perfect (hoàn háo) child, but this one…’ I felt sorry for her for having to go through that, and ashamed not to have a normal child like other women.”

Hà's story had a number of characteristics in common with the stories of other women in our sample. When telling us their stories after the pregnancy termination, some of the women remained silent regarding the abortion experience itself. We interpreted this silence as an expression of intense pain and refrained from asking further questions. Some women, however, such as Hà, seemed to use the researchers as a sounding-board for the feelings and reflections that the experience had generated, which seemed to be woven through with a complexity of different emotional strands, including pain, sorrow, guilt, fear and intense uncertainty.

Sorrow and pain

Nearly all the women involved in our research had wanted and planned their pregnancies, timing them carefully with family obligations, work or studies. They had all looked forward to becoming mothers with pride, joy and anticipation, had begun wearing maternity clothes, had shared the happy news with family and friends and felt emotionally attached to the baby they expected. For some, this pregnancy was their initiation into motherhood, while others had looked forward to having a second or third child. In this situation of intense maternal hope and anticipation, having to decide not to let the child live was deeply existentially troubling for all the women. Many pondered the distinctiveness of the loss they suffered. Even though their obstetrician had advised abortion,¹⁸ most felt that the ultimate decision to terminate the pregnancy had been their own, made in consultation with their relatives.¹⁶ The harshness of their loss seemed to be intensified by the fact that it was “chosen” by themselves. What they lost was not only a child-to-be that they had already begun to feel attached to, but also the social recognition that they would have received as the successful mothers of a healthy and “perfect” child.

Several of the women quoted the Vietnamese saying, “one abortion is like three deliveries” to convey the intense pain of undergoing abortion as compared to giving birth; and some described how, although fully conscious, they entered a state of “nothingness” (không biat gì) at the moment when the fetus was expelled. In most cases, the fetus was dead at delivery, but a few women gave birth to a child that lived for a short while. Hearing the child cry was a tormenting experience. Several mentioned that the pain of this experience was aggravated by labouring in the same room as women who were having healthy infants and sharing the recovery room with them.

Guilt and fear

In Viet Nam, it is commonly believed that ensoulment takes place when the fetus grows into a human form. A late-term abortion therefore poses major ethical problems, forcing women into some kind of engagement with the soul of their child-to-be. Many of the women in our study expressed feelings of pity for their child, a strong urge to protect its soul, and fears that it might resent them for not allowing it to live. Châu, for instance, was 17 weeks pregnant when the child she expected was diagnosed with dilatation of ventricles in the brain. When she was admitted to the maternity ward to have an abortion, we asked her how she was feeling. With tears in her eyes, she responded that this was difficult to say out aloud, and wrote in the researcher's notebook: “I feel it is wrong towards my child. By doing this I take away its right to live, to become a person” (cám thay có toi vai con, làm tha là minh tuoc di quyan duoc song, duoc lam nguoi cua nó).

Many women feared that the fetus would keep haunting them, either as a mental phantom or as a restless spirit which might return and become re-embodied in a subsequent pregnancy, possibly causing repeated mishaps in their future reproductive lives. Out of fear that the sight of the deceased fetus would leave a lasting “mental imprint” on their minds (ám anh), thereby rendering them unable to ever leave this experience behind, nearly all the women avoided seeing the body of the fetus after the termination. While most women found it of urgent importance to know that the fetus was “decently” buried, they themselves did not take part in funeral rituals or other rituals of commemoration: they strove to strike a balance between caring for the fetus by ensuring that it was properly buried while also “forgetting” about it by turning their thoughts towards the future rather than dwelling on a painful past. To ease their process of forgetting, their relatives often kept the location of the grave secret from them and encouraged them to forget about their loss.²⁵

Uncertainty

Few of the women expected to receive an exact diagnosis or detailed explanations of the fetal condition, but they were all struggling with the pain of uncertainty regarding the causes of this reproductive mishap and expressed a need for assistance in ensuring a better outcome of their next pregnancy. While the abortion did avert the birth of a “defective” child, it did not help them to have the healthy child they were hoping for. At the time we met them, they were therefore looking towards the future and struggling with questions such as: Why did this happen to me? What can I do to avoid that it happens again? When can I get pregnant again? How large is the risk of recurrence? What should I do to protect my health after this?

Some blamed themselves. Lan, who had taken medicine for a sore throat during her pregnancy, said: “The fault was probably mine. If I had not taken that medicine, this would not have happened. The fetus might have been normal. I keep thinking of that medicine.” Most of the women were searching their minds to find out what they might have done wrong to have caused this. Was it something they ate, a cold, their working environment? Women whose parents or parents-in-law had been exposed to Agent Orange during the war often feared that it could be the long-term effects of dioxin and that they and their family might keep experiencing reproductive trouble in the future. Bích, who had an abortion at 20 weeks said:

“I had never imagined that something like this could happen to me. I am thin, but I am healthy. This could be caused by a cold or by fever, but I am very rarely ill, I rarely have a cold. So I was shocked and asked, why does this happen to me? Can I ask you, why did this happen to me? Before I get pregnant again I need someone to help me, to counsel me so that this does not happen again. I am so scared now, I don't dare get pregnant again. This is my greatest pain: I don't understand why. We had prepared everything in order to have a child, so why did this happen? Is it because of food I ate? There was bird flu and we did eat a lot of chicken… or was it because of something the chickens ate? Or was it because the fruit that my husband sells has been sprayed with pesticides? But I do always peel and wash our fruit… So was it because of some change in my body? I do not know but my thoughts keep rolling.”

In sum, this experience sowed doubts about their way of living and their reproductive capacities, their worth as wives and mothers, and their present and future position in their kin group. How then were women supported by health care providers in this situation?

How were women supported by the health care services?

Health care providers in this study described late-term induced abortions as emotionally, morally and clinically difficult procedures. Emphasizing her feelings as a woman in this situation, Dr Lan, a senior obstetrician, said: “I don't know how male doctors feel. But as a woman I feel very sorry for the parents. A fetus that has grown so big… it is very troubling. With a smaller fetus one feels a bit lighter at heart. But with a big fetus it is very troubling. Very sad. That's the first thing. Second, the bigger the fetus, the larger the risks. As a doctor, one must be very careful and observant in order to ensure that nothing goes wrong and the uterus is not perforated.”

The physicians, however, said abortions for fetal malformation differed from other abortions by being highly justified socially and morally. All the doctors in our study stressed that if a post-diagnostic abortion could be safely performed, it was a beneficial and necessary intervention to help parents avoid the suffering that life with a severely disabled child would entail. Dr Nga, a female physician, said: “If we know for sure that it is [severely] malformed, there is no reason to keep it. It will only bring pain for other people and for itself. It will never be happy, it will never really become a human being. Or it is not clear if it is a human being.”

Yet while de-emphasising moral and emotional issues and agreeing on the overall benefits of these abortions, most doctors felt troubled if a termination was requested on what, to them, were questionable grounds, such as fetal sex or a minor malformation. Also, the thought that medical mistakes might occur, resulting in an unnecessary abortion of a healthy fetus, was considered as a nightmare scenario. This was the reason why, Dr Lan said, feticide was not practised at this hospital.

The 17 women in our sample all had abortions for reasons that the health care providers found legitimate. The fetal conditions were considered medically grave and if the pregnancy had been maintained, the life prospects of the child would be poor. Doctors described the empathy they felt with their patients and emphasised their responsibility to provide the best possible care for women who were confronted with this situation.

“We have an important role, because children are a person's happiness. Faced with a responsibility like this, which is so large and grave, we must have a high level of expertise. We must also have a sense of responsibility when making the diagnosis. We must be very precise when it comes to describing the situation of the child that is about to be born, in order to give a precise assessment of the problem. When a child is not normal, we must have deep empathy with the family, we must encourage them and help them psychologically. We are the first to inform them, so that moment is very important. It is our responsibility to help them feel better, to help them find peace of mind so that they can continue along the way they have to go.” (Dr Tuan)

Our observations at the hospital confirmed that health care staff recognised what a crisis this was for their patients and usually tried to support the women by talking gently to them and encouraging them keep up their spirits. Still, some doctors, such as the one who attended Hà's abortion, did not hide their feelings of revulsion when confronted with the malformed fetal body. To spare the mother from seeing the fetus after abortion, they ensured that the body was quickly removed from the delivery room, and arrangements regarding burial made with the woman's relatives.

While doctors did their best to treat their patients with empathy and care, the women were given very limited opportunities to talk to health care staff about the issues that troubled them. Hardly any of the women were able to talk to a physician about the condition of the fetus, the prospects for the child if they opted to keep the pregnancy, abortion procedures, implications of the abortion for the mother's health or burial arrangements.¹⁸

Most of the women accepted this limited counselling and information provision without complaint. Like Hà, they met their health care providers with quite humble attitudes and felt grateful for the help they received. A few, however, expressed disappointment. My, for instance, said: “I want the doctors to explain in more detail. I do not understand when they use medical words. They told me my fetus is soaked in water. I do not know the reason why. I still don't understand.” My's fetus had been diagnosed in week 19 with hydrops fetalis. The scanning took place one day and the abortion two days later. My had opted for an abortion because doctors as well as family members encouraged her to, but in retrospect she felt that she had not had adequate time to think through the decision. She still felt uncertain about whether the fetal problem had actually been severe enough to justify the abortion.

When we asked physicians why women were not provided with more information and support, they pointed to the organisation and time pressures of daily work, to their limited training in fetal medicine and the limited access to genetic testing in Viet Nam.

“We are overloaded with work. Also, our knowledge about fetal malformation is not adequate and therefore we cannot counsel the patients. For example, women ask us why their fetuses are malformed and how they can prevent recurrence. We do not know. That is the main problem. We are busy, but we can spend more time with the patients. The most important problem is that I and other doctors in this hospital do not have much knowledge about this.” (Dr Lang)

Yet our research also suggests that in addition to these problems, the provision of care was affected by the separation of “clinical/professional” and “emotional/personal” issues by providers. Physicians tended to classify both their own and their patients' responses to the situation as belonging to the personal sphere, whereas they concentrated their efforts on the clinical/technical tasks of providing the abortion in a clinically safe manner.

Women's reflections two years later

Two years after the abortion, most of the women described having gone through a long-term process of coming to terms with profound loss. For the first few months after the abortion, they had felt very sad, cried a lot and kept thinking of the child they had lost. Their husbands and relatives had encouraged them to stop thinking about the child and look toward the future. But many felt sorry for the lost child and pained to have been the one to decide to end its existence. Liên, for instance, often went to the pagoda to pray for her child, because, as she said: “I made the decision, but the child bears the consequences.”

With time, most of the women said they had regained their balance physiologically and emotionally. Only My described persistent feelings of sadness and regret. After having had the abortion, she learnt that a friend of hers had been through a similar experience. Yet her friend had kept the pregnancy and the child had turned out to be healthy and normal. My therefore felt that she had made the wrong choice and regretted having had the abortion: “It was my child even if it was disabled. I keep wondering whether the abortion was right or not. I wish I had kept the child. Even if it would have been difficult to bring it up, I could accept that.”

With the exception of My, all the women felt they had made the right decision by opting for abortion. In Vietnamese society, the birth of an impaired child is often interpreted in karmic terms and seen as an indicator of moral transgression by the parents or grandparents.¹⁷ Some of the women interpreted their experience in such terms, seeing the detection of the malformation and their ability to access a late-term abortion as indications that, after all, in spite of this reproductive mishap, their families did have “luck” (phúc) in a moral, cosmological sense. Most of the women felt fortunate to have been able to terminate their pregnancies. Even though it was painful, they reasoned, the pain was momentary, whereas having a severely disabled child would have rendered their entire lives painful. Many felt that terminating the pregnancy had been the most humane thing they could have done for the child-to-be as well.

Yet even though the vast majority of the women felt that they had made the right decision, many still thought about and longed for the child they had lost. These feelings of loss and longing were markedly less pronounced among the women who had had a child in the intervening years and were now preoccupied with caring for it, and more pronounced among those who had not been able or felt ready to have another child. Hà was one of the latter. Her elders had encouraged her to wait for a couple of years in order to regain her strength before getting pregnant again, but she and her husband had agreed to try to have a child within the coming year. Other women expressed hesitation and fear at the thought of getting pregnant again. Tuyat, for instance, had not yet dared to try to start another pregnancy: “My elders tell me not to think about the fetus. They say this to console me. But how could I not think about it? I keep thinking about it and I am so scared that something like this will happen again.”

Two women had experienced a miscarriage or an induced abortion in the two years after the termination we observed, and two other women had previously gone through one or more abortions for fetal anomaly. Not knowing how they could enhance their chances of having a healthy child in future, these women were struggling with “why” questions to an even greater extent than the other women.

Thus, two years after the event, most of the women seemed to have come to terms with their experience, yet none had placed it entirely behind them. Those who had been able to give birth to a child seemed more able to have found some kind of closure than women whose reproductive capacities remained in question.

Discussion and conclusion

Late-term abortion for fetal malformation has been found to be a profoundly unsettling experience not only for the women in this study but also in a recent Dutch study where, four months after the termination, a considerable number of parents still had symptoms of stress and depression¹⁴ and a German study in which women interviewed 14 days after the termination and those interviewed 2–7 years afterwards both still had strong grief reactions.¹² There is also evidence, however, that for many women – including many in our study – such distress declines over time and most women and their partners manage gradually to adapt to their loss.¹¹¹³

Anthropological research shows that a reproductive loss can throw a woman into a larger crisis of motherhood and identity²⁶²⁷ because of the centrality of childbearing.²⁸²⁹ It is therefore not surprising that the women in our study who reported least trouble coping with the loss were those who either had a child(ren) already or who got pregnant soon and gave birth to a healthy child. Similar observations have been made in other studies of post-diagnostic abortions and perinatal loss.^9,30 An early study on the psychosocial sequelae of abortions for fetal malformation concluded: “A successful subsequent pregnancy often counterbalanced the loss of biological self-esteem and, to some extent, the feelings of reduced social competence.”⁹

How, then, can health care providers assist women in managing this crisis of life and identity, enhancing their self-confidence in beginning a new pregnancy? Research in Europe has shown that women's distress can be lessened if they are provided with psychosocial care and empathic professional support. This includes the provision of accurate information about the malformation and its probable causes, about risks to future pregnancies, as well as offering women the opportunity to share their feelings and, if they wish, to be involved in decisions regarding the abortion procedure.^8,11 Some authors have suggested that it may be important for women who suffer reproductive losses to get to see and hold the child after the termination, to organise the farewell through burial and rituals, and to be provided with a photograph as a tangible memory of the child.¹¹²⁶ Our research in Viet Nam indicates that when caring for women who undergo post-diagnostic abortions, it is important to take into account cultural variations in ritual responses to bereavement and cultural perceptions of the ontology of early human life.³¹ In a social setting where it is often feared that a visual, mental “imprint” of the deceased fetus may haunt the woman for years to come, encouraging women to see, hold or take photographs of the deceased fetal body may not be helpful modes of support.

While empathic counselling is generally recommended, women in our study were rarely offered the opportunity to share their feelings or obtain answers to the questions that troubled them. Similar limitations in terms of support and counselling in abortion care were documented in a recent qualitative study from Vietnam which found that many women obtaining second trimester abortions were motivated by fears of fetal anomalies, yet these fears were not medically grounded and could perhaps have been resolved through counselling.³² According to doctors in our study, more advanced training in ultrasonography and fetal medicine and better access to technologies for genetic testing such as amniocentesis could enhance their capacity to support women undergoing post-diagnostic abortions.

Our research also suggests, however, that more than technical skills are at issue. The capacity of providers could also be strengthened by preparing them to cope with the troublesome emotions and moral dilemmas that new technology has given rise to. A recent study from France found that 25% of midwives felt morally troubled and 65% found their role as a midwife difficult when involved in termination of pregnancy for fetal abnormality. 70% of them reported feeling compassion and 49% feelings of sadness, while 20% had difficulties touching the dead child. This study recommended training midwives in the psychological and ethical aspects of late-term abortions.³³

Unlike most induced abortions, an abortion for fetal anomaly is usually for a woman who had intended to carry the pregnancy to term. This study suggests that the Vietnamese health care system could expand the way in which screening and testing for fetal anomalies are provided to ensure women receive counselling and personal support that takes into account specific socio-cultural beliefs, answers women's questions, addresses their concerns and helps them to realise their reproductive desires. More information could also be provided to women regarding the abortion procedure and post-abortion care. To enhance the capacities of health care staff, additional training in ultrasonography, fetal medicine and genetic testing are important. Further training in counselling and communication skills and sensitisation of health care providers to the social, emotional and ethical challenges that detection of fetal anomalies and this new kind of abortion brings to medical practice are necessary.

Acknowledgements

This article is based on research funded by the Council of Development Research of the Danish International Development Assistance (Danida). We wish to acknowledge the contributions of our colleagues in Viet Nam to data collection and analysis, in particular Nguyan Huy Bao, Thanh Toàn, Bùi Kim Chi and Hoàng Hai Vân. We also thank staff at the maternity hospital and the women and their families who participated in the research. A draft of this article was presented at the ICMA International Conference on Second Trimester Abortion, London, 29–31 March 2007.