Second Trimester Abortion in Viet Nam: Changing to Recommended Methods and Improving Service Delivery

Abstract

In Viet Nam, abortion has been legal up to 22 weeks of pregnancy since the 1960s. There are about one million induced abortions every year. First trimester abortion is provided at central, provincial, district and commune level, while second trimester abortion is provided only at central and provincial level. For second trimester abortion, dilatation and evacuation (D&E) has been introduced at some central and provincial hospitals, and medical abortion protocols have been included in the draft National Standards and Guidelines currently being updated. However, Kovac's, an unsafe method, is still often used at many provincial hospitals. While access to first trimester abortion services is not difficult, there are still many barriers to second trimester abortion, especially for young, unmarried women. In order to prevent unwanted pregnancies, increase access to safe abortion and improve quality of care, the Vietnamese Ministry of Health is working with others to establish national policies and developing effective models for women-friendly comprehensive abortion care, including post-abortion family planning. This paper, based on published information, interviews and observations by the second author of service delivery in 2006–2008, provides an overview of second trimester abortion services in Viet Nam and ongoing plans for improving them.

Résumé

Au Viet Nam, depuis les années 60, l'avortement est légal jusqu'à 22 semaines de grossesse. Près d'un million d'avortements y sont pratiqués chaque année. L'avortement du premier trimestre est assuré aux niveaux central, provincial, du district et de la commune. Pour l'avortement du deuxième trimestre, certains hôpitaux centraux et provinciaux ont introduit la méthode par dilatation et évacuation, et le projet de normes et directives nationales qui est actuellement mis à jour inclut des protocoles d'avortement médicamenteux. Néanmoins, même si elle n'est pas sûre, la méthode Kovac est encore souvent utilisée dans beaucoup d'hôpitaux provinciaux. Alors que l'accès à l'avortement du premier trimestre est aisé, de nombreux obstacles demeurent à l'avortement du deuxième trimestre, en particulier pour les jeunes femmes célibataires. Afin d'éviter les grossesses non désirées, élargir l'accès à l'avortement médicalisé et relever la qualité des soins, le Ministère vietnamien de la santé collabore avec d'autres institutions pour définir des politiques nationales et établir des modèles efficaces de services d'avortement centrés autour des femmes, notamment de planification familiale post-avortement. Cet article, fondé sur des informations publiées, des entretiens et l'observation de la prestation de services par les auteurs en 2006-2008, décrit les services d'avortement du deuxième trimestre au Viet Nam et les projets en cours pour les améliorer.

Resumen

En Viet Nam, el aborto es legal hasta las 22 semanas de embarazo desde la década de los sesenta. Cada año se inducen aproximadamente un millón de abortos. A nivel central, provincial, distrital y comunal, se proporcionan servicios de aborto en el primer trimestre, mientras que los de segundo trimestre son proporcionados sólo a nivel central y provincial. Para este último, la dilatación y evacuación (D&E) ha sido introducida en algunos hospitales centrales y provinciales, y los protocolos de aborto con medicamentos se han incluido en la versión preliminar de las Normas y Directrices Nacionales, en proceso de actualización. Sin embargo, Kovac, un método inseguro, aún se utiliza con frecuencia en muchos hospitales provinciales. Aunque no es difícil acceder a los servicios de aborto en el primer trimestre, todavía existen muchas barreras al aborto en el segundo trimestre, especialmente para las mujeres jóvenes y solteras. A fin de evitar embarazos no deseados, ampliar el acceso al aborto seguro y mejorar la calidad de la atención, el Ministerio de Salud de Viet Nam está trabajando con otros para establecer políticas nacionales y crear modelos eficaces para la atención integral del aborto centrada en la mujer, que incluyan la planificación familiar postaborto. En este artículo, basado en información publicada, entrevistas y observaciones de los autores de la prestación de servicios en 2006–2008, se proporciona una visión general de los servicios de aborto en el segundo trimestre en Viet Nam y de los planes en curso para mejorarlos.

Key Words:

• second trimester abortion
• adolescent reproductive health
• contraception and unplanned pregnancy
• Viet Nam

Abortion has been legal in Viet Nam since the 1960s. Historically, together with contraception, abortion was considered as a means to control population growth in Viet Nam. Now the law allows each couple or individual to decide the number and spacing of their children. People also have the right to choose which contraceptive method to use and are obligated to use contraception.¹ Viet Nam is considered to have one of the highest abortion rates in the world – about 500,000 abortions were reported from the public sector in 2006² and at least the same number have been provided in the private health sector (Interviews with gynaecologists at Ha tay, February 2006; Hai phong & Lao cai, March 2006; and Bac ninh, August 2006). The ratio of abortions to live births is high: 45.1 abortions per 100 live births.³ In spite of a liberal law, unsafe abortion is still a common cause of maternal death, estimated at 11.5% of direct causes of maternal mortality in Viet Nam in 2002.⁴

This paper, based on published information, interviews and observations by the second author of service delivery in 2006–2008, provides an overview of second trimester abortion services in Viet Nam and ongoing plans for improving them.

There are no official data on second trimester abortion in Viet Nam. The proportion of second trimester terminations differs widely between hospitals, from 3% of abortions at the National Obstetrics and Gynecology Hospital to 19–20% at Tu Du Obstetrics and Gynecology Hospital.⁵⁶ About 53% of those having a second trimester abortion are young unmarried women.⁷ According to the Ministry of Health's National Reproductive Health Standards and Guidelines, abortion is legal up to 22 weeks, though depending on the capacity at each level of hospital. At the central hospitals, abortions can be done up to (and in a few cases above) 22 weeks, especially for unmarried women. At the district level, abortion is allowed up to 12 weeks, and at the commune level it is limited to six weeks only. Access to second trimester abortion is therefore more restricted in comparison to first trimester abortion, because second trimester procedures carry more risk and require more skilled providers and specific instruments.

Why Vietnamese women have second trimester abortions

Women access abortion services late for the following reasons. Many are not aware they are pregnant. Since the Family Planning Program in Viet Nam focuses only on married couples, young people do not receive sexuality education, and do not know where to get contraceptive methods or where to go if they are pregnant. A qualitative study of why women delay abortion until the second trimester, conducted in May–August 2005, interviewed 60 women in eight health facilities in Viet Nam. It found that 80% of those interviewed had failed to recognise they were pregnant before 12 weeks of gestation.⁷ Some women did not notice that their period had not come, and some who were not using any contraception did not think they would get pregnant because of irregular sexual intercourse.

In about 20% of the cases in that same study, the women had needed a month or more to make the decision, due to difficulties reconciling conflicting social norms or their socio-economic situation with their desires regarding the pregnancy. This happens commonly among young and unmarried women, especially adolescents. One adolescent said that she would not be able to return to her family in her homeland if her pregnancy was discovered, and another young woman said her parents would kill her if they knew that she had had sexual intercourse and become pregnant. Some women described negative consequences for their educational or employment opportunities. Some had waited to try and convince their partner to get married but failed. In some cases, women come to the health sector early, but pregnancy detection is delayed due to the poor quality of early pregnancy tests, and this can push the abortion into the second trimester.⁷

As in a number of other Asian countries, son preference exists in Viet Nam. Sex selective abortion is becoming an issue in the country, which the government is concerned about and has made policies to try and prevent it.⁷⁸ According to estimated population data by age and sex in 2006, the male population under 20 years of age is somewhat higher than the female population in the same age group.² A lot of Vietnamese consider that one boy child is better than a dozen girls. Nowadays, ultrasound scans have become very popular in Vietnam.⁹ They are used both to screen for fetal anomalies and sometimes for sex determination. Many pregnant women learn their child's sex by their 15th week. With abortion possible up to 22 weeks, some women seek abortion for sex selection.

Antenatal screening for detecting abnormalities in pregnancy has become more and more popular in Viet Nam, especially at the tertiary level. Most tests can only be used in the late first trimester or second trimester, which also leads to second trimester terminations in some cases.¹⁰

Second trimester abortion methods: phasing out outdated methods

At the central and provincial hospitals providing second trimester abortion, three methods are being used: Kovac's, D&E and medical abortion. Traditionally, over many years, many hospitals have used the Kovac's method, whereas D&E and second trimester medical abortion have not yet been applied broadly. So far, staff in only two central hospitals – National Obstetrics & Gynecology Hospital and Tu Du Obstetrics & Gynecology Hospital – and in seven provincial hospitals have been trained and provide D&E. Second trimester medical abortion is provided at central level in NOGH and Tu Du hospitals and several provincial hospitals, but each hospital is using different protocols (Observations at Hai Phong Ob-Gyn Hospital, October 2006; Tu Du Hospital & Khanh Hoa General Hospital, November 2007; and National Obstetrics & Gynecology Hospital, December 2007).

Both D&E and medical abortion are recommended by the World Health Organization (WHO)¹¹ and are used in many countries. But the Kovac's method – extra-amniotic saline infusion – still seems to be in use in several countries, in spite of its lower effectiveness and safety and long amount of time required for the abortion to be complete. It is considered completely outdated and has long been out of use in developed countries.¹²

D&E is carried out in Viet Nam at 13–18 weeks of pregnancy. This method requires preparation of the cervix and evacuation of the uterus with suction and special forceps. Cervical preparation will be carried out in Viet Nam with misoprostol. According to the National Guidelines, misoprostol should be administered sublingually or buccally, 400–800 mcg, at least four hours before dilatation and evacuation.¹³ This method has been approved by the Vietnamese Ministry of Health since 2003. Almost all women are able to leave the hospital several hours after abortion. However, it is necessary to have skilled and experienced providers, and proper equipment.

In the Kovac's method, the cervix is dilated mechanically, and a condom-covered catheter with saline solution is introduced into the uterine cavity, stimulating prostaglandin secretion, to induce labour, resulting in uterine contractions. This method is used only for pregnancies of 18–24 weeks gestation. It usually takes about one week of hospitalisation for the whole process with this method, which increases the cost of abortion and contributes to a situation of overload in the hospitals, especially at central level, as in Tu Du hospital. Kovac's is also associated with serious complications, including haemorrhage, uterine rupture and sepsis. Reliance on this method delays women receiving services until after 18 weeks of pregnancy, even when they first present early in the second trimester, which creates a lot of emotional pressure on women while they are waiting for the pregnancy to advance sufficiently.¹⁴

The recommended second trimester medical abortion methods are a combination of mifepristone and misoprostol or misoprostol alone.¹² Although these are being used widely in many other countries, and are both effective and safe, they have not yet been introduced into the regular abortion services in Viet Nam. In the National Guidelines for providing reproductive health services in Viet Nam, medical abortion has just been approved for use in the first trimester.¹³ Almost all the medical abortions carried out in the second trimester are part of studies conducted at central or provincial levels. Tu Du Hospital has just begun to apply the following regimens of misoprostol alone to terminate second trimester pregnancies: 400 mcg misoprostol inserted vaginally every 3 hours for pregnancies of 16–19 weeks and every 6 hours for pregnancies of 20–22 weeks. This new (for Viet Nam) method is very safe and effective, but as with all abortions, it is important to monitor the woman closely during the abortion process in case of complications.¹⁵

Barriers in access to services

Although second trimester abortion services are provided at central and provincial hospitals, there still many barriers for women needing one. The first is the complicated administrative process at public hospitals. While the administrative process for married women who come for first trimester abortion is quite simple, requiring neither an identification document nor a husband's approval (Observations at Bac ninh, August 2007; Tu Du Hospital, Hung yen & Khanh hoa, November 2007; National Obstetrics & Gynecology Hospital, December 2007; and Ba ria–Vung tau, April 2008), the process is very complicated for second trimester abortion, especially for unmarried young women. They often have to present their identification document, their age and address. If they are younger than 18 years, they will need a parent's or guardian's approval (Observations at Tu Du Hospital, November 2007, and National Obstetrics & Gynecology Hospital, December 2007).

The second barrier is unfriendly attitudes of abortion providers. As Vietnamese culture is against premarital sexual intercourse, health providers often treat unmarried women seeking abortions badly. One issue, often of great concern for young unmarried women, is the lack of confidentiality and privacy at public hospitals.¹⁶ For these reasons, young unmarried women often seek abortions in the private sector (Interviews with gynaecologists at Ha tay, February 2006; Hai phong & Lao cai, March 2006; and Bac ninh, August 2006), where second trimester abortions are not permitted and are often unsafe. Some young unmarried women go to untrained providers or even quacks, which leads to very poor outcomes and even deaths. This is the main reason why there are still deaths from unsafe abortion in Viet Nam (Interview young unmarried abortion patient, Thai Nguyen Hospital March 2006; and interview with gynaecologists, Hoa Binh Reproductive Health Care Centre, June 2007).

The third barrier is the high cost of these services. Second trimester abortion is often too expensive for poor women and is especially out of reach of young women, such as students, who have no income.¹⁷ In addition, women in remote areas often have much more difficulty accessing second trimester abortion services due to the lack of rural facilities with competent providers and sufficient equipment (Interview with providers, Hoa Binh Reproductive Health Care Centre, June 2007).

Plans to improve the situation

In the National Standards and Guidelines for Reproductive Health Care Services of 2003 the only recommended method for second trimester abortion is D&E. The Ministry of Health is working with a safe abortion expert group with technical support from Ipas, WHO and Pathfinder International to update the guidelines to include, among other changes, medical abortion in the second trimester with two protocols, one for combined mifepristone–misoprostol and one for misoprostol only. The new version is planned to be approved and published in early 2009. Then the training materials will be updated to disseminate these safe abortion techniques in Viet Nam.

Because D&E services are provided at only two central obstetrics & gynaecology hospitals and seven provincial hospitals, the Ministry of Health and two central hospitals have plans to train providers in more provincial hospitals in D&E. After the new National Standards and Guidelines and accompanying training material are published, a series of training courses in the new techniques will be put into the Ministry of Health plan. Since D&E requires specific instruments, which are produced abroad and very expensive, the Ministry of Health will need to have a strategy for sustainable procurement of D&E instruments, such as finding products for import at a reasonable price or, even better, arrange to have these made locally.

No less important in increasing women's access to services is the promotion of women-friendly services. The Ministry of Health has worked with Ipas Viet Nam, the National Obstetrics & Gynecology Hospital and Tu Du obstetrics & gynecology hospital, and two provinces, Hai phong and Dong nai, their districts and communes, with financial support from Ford Foundation, to develop a model for comprehensive abortion care, where women are at the centre of service delivery. In this model, the administrative process is simplified as much as possible and all unnecessary tests such as the blood formula test and time of blood bleeding & time of coagulation are eliminated. The model also aims to improve the quality of counselling and ensure privacy throughout the abortion process, as well as link abortion with contraceptive services.¹⁷¹⁸ D&E has been introduced in this model as a safe technique for second trimester abortion. The model has already been scaled up at five other provincial hospitals in Viet Nam in conjunction with the Ministry of Health, Ipas and Ford Foundation. A strong team of trainers in comprehensive safe abortion care is being developed in order to scale up this very successful model in more provinces.

Last but most important is primary prevention. Because many women, especially young unmarried women, have poor knowledge about preventing unwanted pregnancy and lack of awareness of the signs of early pregnancy, Viet Nam has a long-term strategy for Adolescent Reproductive Health Education through direct information channels, including teachers, friends, colleagues, society, parents and relatives.¹⁹ Furthermore, cultural disapproval is an invisible barrier for young unmarried people to access contraceptive methods and abortion services when they are needed. This strategy aims to promote friendly reproductive and sexual health services for young people. The Ministry of Health has developed Guidelines for Youth-Friendly Health Services, which focus on providing information and counselling on adolescent reproductive health, and promoting contraceptive methods, using a right-based approach.²⁰ Using these guidelines, the Viet Nam National Target Program on Adolescent- and Youth-Friendly Health Services is being implemented in 20 provinces in the country by the Vietnamese Ministry of Health, with support from WHO.

Although safe techniques for second trimester abortion have been introduced in Viet Nam and many positive programmes are being implemented, the Ministry of Health, hospitals, social agencies and individual providers still have a lot of work to do in order to improve quality of abortion care, increase access to safe services and decrease the need for second trimester abortion by promoting effective contraceptive use and providing early abortion services for women with unplanned pregnancies.

Acknowledgements

The authors would like to thank the Maternal & Child Health Department of the Viet Nam Ministry of Health, Ipas Viet Nam, Ipas North Carolina, National Obstetrics & Gynecology Hospital, Tu Du Hospital, Barbara Crane, Do Thi Hong Nga, Alyson Hyman, Pham Viet Thanh, Phan Van Quy, and Hoang Bich Thuy.