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Induced abortion among HIV-positive women in Quang Ninh and Hai Phong, Vietnam

2010; Wiley; Volume: 15; Issue: 10 Linguagem: Inglês

10.1111/j.1365-3156.2010.02604.x

1365-3156

Bùi Kim, Tine Gammeltoft, Nguyen Thi Thu Nam, Vibeke Rasch,

Adolescent Sexual and Reproductive Health

Objectives To explore the decision of induced abortion among HIV-positive women and examine how the decision is associated with socioeconomic characteristics and the availability of comprehensive programmes aiming at preventing mother to child transmission of HIV. Methods A descriptive cross-sectional study was conducted in two provinces of Northern Vietnam. In all 707 HIV-positive women were recruited through collaboration with commune health centres and peer groups. Information was obtained on women's socioeconomic characteristics and pregnancy outcomes before and after HIV diagnosis. Odds ratios (ORs) with 95% confidence intervals (CI) were calculated to measure the association between socioeconomic characteristics and induced abortion. Results Among women who had been pregnant while being aware of their HIV-positive status, 68% stated having had an induced abortion, whereas 22% of the women who had not been aware of their HIV status stated the same. Induced abortion after HIV diagnosis was associated with being aged 30 or older (OR 5.44, 95% CI 1.28–23.02), being petty traders or independent labourers (OR 3.61, 95% CI 1.05–12.45) and being diagnosed with HIV in 2004 and earlier (OR 2.96, 95% CI 1.02–8.53). Conclusions Awareness of HIV-positive status is related with an increased tendency to have an induced abortion. L'avortement provoqué chez les femmes VIH-positives à Quang Ninh et Hai Phong au Vietnam Objectifs: Explorer la décision pour l'IVG chez les femmes VIH séropositives et examiner comment la décision est associée à des caractéristiques socioéconomiques et la disponibilité des programmes complets visant à prévenir la transmission mère-enfant du VIH. Méthodes: Une étude transversale descriptive a été réalisée dans deux provinces du nord du Vietnam. Au total 707 femmes VIH séropositives ont été recrutées grâce à la collaboration avec les centres de santé communaux et groupes équivalents. Les informations sur les caractéristiques socioéconomiques des femmes et les résultats de la grossesse avant et après le diagnostic du VIH ont été obtenues. Les odds ratios (OR) avec un intervalle de confiance (CI) de 95% ont été calculés afin de mesurer l'association entre les caractéristiques socioéconomiques et l'avortement. Résultats: Parmi les femmes qui ont eu une grossesse tout en étant conscientes de leur séropositivité, 68% ont déclaré avoir recouru à une IVG comparéà 22% des femmes qui n'avaient pas été au courant de leur statut VIH avant la grossesse. L'IVG après le diagnostic du VIH était associée au fait d'être âgé de 30 ans ou plus (OR= 5,44; IC95%: 1,28 - 23,02), être une petite commerçante ou une agricultrice indépendante (OR = 3,61; IC95%: 1,05 - 12,45) et avoir été diagnostiquée avec le VIH en 2004 ou plus tôt (OR= 2,96; IC95%: 1,02 - 8,53). Conclusions: La connaissance du statut VIH positif est liée à une tendance accrue à avoir une IVG au Vietnam. Aborto inducido entre mujeres VIH positivas en Quang Ninh y Hai Phong, Vietnam Objetivos: Explorar la decisión de un aborto inducido entre mujeres VIH positivas y examinar como la decisión está asociada a las características socioeconómicas y la disponibilidad de programas integrales de prevención de la transmisión del VIH de madre a hijo. Métodos: Estudio croseccional descriptivo realizado en dos provincias del norte de Vietnam. En total se reclutaron 707 mujeres VIH positivas, en colaboración con centros sanitarios comunitarios y grupos de apoyo. Se obtuvo información sobre las características socio-económicas de las mujeres y los resultados del embarazo antes y después del diagnóstico de VIH. Se calculó la oportunidad relativa (odd ratio - OR) con un intervalo de confianza (IC) del 95% para medir la asociación entre las características socioeconómicas y el aborto inducido. Resultados: Entre las mujeres que habían estado embarazadas siendo conscientes de su estatus VIH positivo, un 68% dijo haber tenido un aborto inducido, mientras que entre las mujeres que no conocían su seroestatus el porcentaje de abortos inducidos era del 22%. El tener un aborto inducido después del diagnóstico del VIH estaba asociado con el ser mayor de 30 (OR 5.44, 95% IC 1.28-23.02), ser minoristas o trabajadores independientes (OR 3.61, 95% IC 1.05-12.45) y el haber sido diagnosticado con VIH antes de o durante el 2004 (OR 2.96, 95% IC 1.02-8.53). Conclusiones: El conocimiento de ser VIH positiva está relacionado con una mayor tendencia a tener un aborto inducido en Vietnam. Approximately half the population of HIV-positive cases are women and most of them reside in low- and middle-income countries (UNAIDS 2008). In 2008, an estimated 1.4 million HIV-positive pregnant women gave birth. The percentage of HIV-positive pregnant women who received antiretrovirals (ARVs) to prevent HIV transmission to their children increased from 10% in 2004 to 45% in 2008 (WHO 2009). HIV-positive women confront difficult decisions related to their pregnancy (Cooper et al. 2007; Delvaux & Nöstlinger 2007). Many studies have tried to assess the rate of induced abortion among HIV-positive women in high income countries, whereas little research has been carried out on this area in low- and middle-income countries (Delvaux & Nöstlinger 2007). Studies from high-income countries, conducted before comprehensive programmes aiming at preventing mother to child transmission (PMTCT) of HIV were implemented and before access to ARV treatment became widely available, have shown that women were more likely to terminate their pregnancy when they learnt they were HIV positive (Thackway et al. 1997; Van Benthem et al. 2000). Other studies have shown that after the introduction of PMTCT programmes, the rate of induced abortion among HIV-infected women decreased. However, induced abortion is still prevalent among HIV-positive women (Bongain et al. 2002; Massad et al. 2004). In Vietnam, the HIV prevalence among pregnant women has increased from 0.30% in 2001 to 0.37% in 2006 (UNGASS 2008). Like many HIV-positive women throughout the world, Vietnamese pregnant women face hard decisions of childbearing (Bui KC, Rasch V, Nguyen TTH & Gammeltort. Pregnancy decision-making among HIV-positive women in Northern Vietnam: Reconsidering reproductive choice (Oosterhoff et al. 2008). Studies have documented that cultural values have a strong impact on Vietnamese women's childbearing decisions (Gammeltoft 2007). Being pregnant, HIV-positive women are under the pressure to have a child, particularly a son to maintain family lineage (Oosterhoff et al. 2008). Yet, at the same time, the women are also concerned about how to take care of their children in the context of financial constrains and concerned about the risk of leaving their children orphaned and the stigma and discrimination their children may face (Bui et al. 2010). Induced abortion is legal and common in Vietnam (Teerawichitchainan & Amin 2009), but the reported number of abortion cases is still underestimated because of under-reporting from private facilities in which many abortions are performed (Sedgh et al. 2007). The number of menstrual regulation and abortions from the public sector in Vietnam in 2008 is 332 154 (SRV 2009). Vietnamese women tend to use induced abortion to achieve their desired family size in the context of inadequate availability and inefficient use of contraceptives (Teerawichitchainan & Amin 2009). Quang Ninh and Hai Phong, where this study was conducted, are two of the five provinces in Vietnam which are hardest hit by the HIV epidemic. In 2005, HIV-positive women in Quang Ninh and Hai Phong accounted for, respectively, 7.0% and 10% of all HIV-infected persons, and the prevalence rates among pregnant women were reported to be 1.0% in Quang Ninh and 0.3% in Hai Phong (VMOH 2006). The 2008 reported number of induced abortion in Quang Ninh and Hai Phong was relatively high among cities/provinces in Vietnam (12 866 and 3441, respectively) (SRV 2009). Scale up of PMTCT and ARV treatment has during the past years become a priority in Vietnam. The country is aiming at offering HIV counselling and testing to 90% of pregnant women and providing prophylactic interventions to 100% of those testing HIV positive by the year 2010 (Morch et al. 2006). To achieve this aim, the government has since 2004, with the support of international donors, established and scaled up PMTCT and ARV treatment programmes in a number of selected provinces and is planning to expand the scale up to other provinces. This article explores the decision of induced abortion among HIV-positive women in two northern Vietnamese provinces and examines how the decision is associated with socioeconomic characteristics and the availability of comprehensive PMTCT programmes. The findings of this study will make a contribution to a better understanding of reproductive choice among HIV-positive women in Vietnam in the context of PMTCT availability. Such knowledge is believed to be important to better help women to make an informed choice related to pregnancy. Two approaches were used to recruit HIV-positive women in Quang Ninh and Hai Phong. The women in Quang Ninh were identified through the HIV register where a total of 518 women were listed. Of these women, 108 had provided a wrong address and 24 were not at home at the time of the study. We thus managed to invite 386 HIV-positive women to participate in the study, and 351 women accepted participation. The women in Hai phong were approached through a combined use of the HIV register and the PLWHA networks. Three hundred and twenty-four women were identified through the PLWHA networks and 310 accepted to participate. The women identified through the PLWHA networks were checked against the HIV register, which included 743 HIV-positive women. Of these registered women, 226 were found to have been included in the study by the PLWHA approach. Attempts were made to include the remaining 517 registered HIV-positive women, but 82 were not living in Hai Phong and 378 had provided wrong addresses or had been registered incompletely. Thus, another 57 women from the HIV register were eligible for the study, and 46 of these women accepted participation. Thus, 356 HIV-positive women (310 from the PLWA networks and 46 from the HIV register) from Hai Phong participated. In sum, 707 of 1261 HIV-positive women in Quang Ninh and Hai Phong were included in the study, equivalent to a response rate of 56%. Data were collected during the period of April–November 2007. A community-based approach was used, where the women were approached through collaboration with the community health centres that provide home-based care and monitor HIV cases and through PLWHA groups where HIV-infected people receive support to access care and treatment. The community health workers, who according to the national guidelines on PMTCT and ARV treatment are responsible for having contact with the registered HIV-infected persons, established the contact with study participants. The health workers contacted the eligible women through phone or through home visits, introduced the study and invited the women to participate. The women were explained the purpose of the study that helps women to make informed reproductive choice. If the women accepted, an appointment was made. Structured face to face interviews were performed. The interviews focused on the women's sociodemographic characteristics, the time of HIV infection, their social network and pregnancy outcomes before and after being diagnosed with HIV. In addition, the reasons to have an abortion were investigated. The interviews were conducted in different places, chosen by the women: at their homes or at the health centres of the commune where they lived or at the offices of the clubs for PLWHA in which they participated. Each interview took about 40 min; only the interviewer and the woman were present. We used the Statistical Package for the Social Sciences (spss), version 15.0, for statistical analysis. The outcomes of the last pregnancy before HIV diagnosis and outcomes of the first pregnancy after HIV diagnosis were explored. Odds ratios (ORs) were calculated with the group of women who had induced abortion as the dependent variable in comparison with women who gave birth. Whether the women were tested before or after 2004, where PMTCT and ARV became available, were believed to have an effect on the other variables under study. Therefore, logistic regression analysis was performed where time of HIV testing was controlled for. All associations are presented as ORs with 95% CI. The women were assured strict confidentiality and anonymity. Informed consent was obtained, and the study was ethically approved by the Scientific Committee of the Vietnamese Commission for Population, Family and Children and by the Danish National Committee on Biomedical Research Ethics. Table 1 describes the sociodemographic characteristics of the study participants. The age range of the women was 18–53, and the majority were 25–29 (36.5%). Nearly half of women were widowed. Most women had completed either lower or upper secondary school (37.9% and 32.1%, respectively), and many worked as petty traders and independent labourers (40.9%). The majority of women reported that they had become infected from having sexual relations with their husbands (80.3%). At the time of the survey, more than half of women had one live child (51.5%). Fewer than half of the women were under ARV treatment, and 60.5% had been diagnosed as HIV positive after 2004 when the PMTCT and ARV programs became widely available in Quang Ninh and Hai Phong. To document the association between awareness of HIV status and induced abortion, the women were asked about the outcome of their last pregnancy. Among women who had been aware of their HIV-positive status, 68% stated having had an induced abortion; in contrast, only 22% of the women who had not been aware of their HIV status stated the same (Table 2). Of all 99 women who had been pregnant while aware of their HIV-positive status, 69 had been pregnant before 2004 and 30 after 2004. Among women who had been pregnant before 2004, 75% had had an induced abortion, whereas this applied to 50% of the women who had been pregnant after 2004, i.e. when PMTCT services became more widely accessible (Table 3). The association between pregnancy outcomes and socioeconomic characteristics among the 99 women who had been pregnant after HIV diagnosis is presented in Table 4. Significant associations were found between induced abortion and age, occupation and time of HIV diagnosis. Women who were aged 30 or older were five times more likely to have an induced abortion than women who were younger than 30. Petty traders and independent labourers were four times more likely to have an induced abortion than housewives. Also, women who were diagnosed with HIV in 2004 and earlier had a three times increased OR for having experienced an induced abortion after HIV diagnosis compared to women who were diagnosed as HIV positive after 2004. This association did not change when adjusted for the effect of time of HIV diagnosis although the effect of occupational situation became less pronounced. Table 5 shows that the majority of women were in the first trimester of pregnancy (91%) when they had an abortion after HIV diagnosis. The fear of mother to child transmission was the main reason for deciding to terminate an unwanted pregnancy (74.6%), followed by difficult economic situation (10.4%). Regarding decision-making, it had often been a joint decision made by the woman and her partner (43.3%); however, almost one-third of the women stated that it was mainly themselves who were the decision-makers. In addition, parents often played a significant role in this decision-making process (16.4%). The women in our study were likely to terminate their pregnancy after HIV diagnosis. The risk factors associated with induced abortion were being aged 30 or older, being petty traders or independent labourers and having been diagnosed with HIV before 2004. A strength of the combined approach to HIV-positive women used in Hai Phong in the present study is that women were identified through different channels to achieve the maximum sample size. Meanwhile, a risk of selection bias was found in the study population approach in Ha Long and Cam Pha, Quang Ninh. Although the majority of women who participated in peer groups of PLWHA were listed in the HIV register, by identifying women only through the HIV register, some new infected women in community were not enrolled. An inherent weakness of the present study is the low recruitment rate (56%). This may raise the concern of the representativeness of the study population. In a component of the same study, it has been documented that young women are under-represented. Because young women are more likely to be involved in unstable partner relationships and thus might be more likely to opt for an induced abortion if experiencing an unplanned pregnancy, it may be argued that the abortion decision would have been more common if the study had covered the young women to the same extent as older women. Further, because the study is focusing on events (time of HIV diagnosis and abortion decision) that had occurred some years back, there is a risk of recall bias. However, being diagnosed as HIV positive is a crucial event not easily forgotten and most likely the women would be able to remember the time of HIV diagnosis as well as the outcome of their first pregnancy after being diagnosed as having HIV infection. In addition, in a Vietnamese context, induced abortion is acceptable and misreporting is most likely not a problem in comparison with other countries, where induced abortion is illegal. The decision of abortion, if being HIV positive, was common in the present study where two-thirds of the women who got pregnant after HIV diagnosis opted for an induced abortion. This finding is in line with other studies that have shown a similar trend of abortion after HIV diagnosis. For instance, an Australian study from 1994 claimed that 47% of the women who had been pregnant after an HIV-positive test result terminated their pregnancy, a rate more than double that of the general population (Thackway et al. 1997). A similar finding was found in a European cohort of HIV-infected women in 1993, showing an 1.8 increased risk of induced abortion among women who became pregnant after HIV diagnosis in comparison with women who were pregnant before HIV diagnosis (Van Benthem et al. 2000). These studies were performed before PMTCT programs became widely and freely available. An American study conducted after introduction of PMTCT documented that 36% of HIV-positive women had an abortion (Massad et al. 2004). The time of HIV diagnosis was associated with the decision of abortion. Hence, women who tested positive before PMTCT and ARV became widely available in 2004 were more likely to have experienced an induced abortion in comparison with women who were tested after 2004. In other words, the availability of PMTCT interventions as a means of reducing the chances of infant infection encourages HIV-positive women to reconsider childbearing. Similarly, a number of studies in high-income countries assert an impact of PMTCT programs on pregnancy outcomes. For example, in a prospective study in two southern French university hospitals from 1985 to 1997, Bongain et al. (2002) observed the decreased proportion of abortions from 59.4% before the availability of PMTCT to 37.5% thereafter. An American study documented that induced abortion became less common (OR 0.46, 95% CI 0.23–0.90) after the introduction of highly active antiretroviral therapy (HAART) compared with before (Massad et al. 2004). Blair et al. (2004) also indicated that HIV-positive women in the United States were more likely to become pregnant (adjusted rate ratio 1.3, 95% CI 1.0–1.6) in the era of HAART than women under other ARV regimens. A recent study from Tamil Nadu, India, revealed that with the availability of PMTCT services including counselling on the prevention of vertical transmission and the detailed information on treatment, delivery and post-delivery procedures, women became more confident in deciding to have a child (Kanniappan et al. 2008). Socioeconomic characteristics such as age, marital situation and number of children are, regardless of the legal status of abortion or the prosperity of the country, well-known risk factors related to induced abortion (Rasch et al. 2008; Rasch & Kipingili 2009). This also applies in Vietnam where data from the National Health Survey indicate that age, marital status, education and number of children are strongly associated with induced abortion (Teerawichitchainan & Amin 2009). We found a significant positive association between being older than 30 and opting for an induced abortion, whereas no association was found between the number of children and induced abortion. A similar influence of HIV-positive women's age on their childbearing was observed in a study from the Midwest where only 11.1% of women aged over 30 chose to become pregnant in comparison with 39.5% of women aged 30 and under (Craft et al. 2007). The fact that number of children was not related to abortion in the present study might reflect the fact that many HIV-positive women are caught in a reproductive dilemma. Many women are young and have not yet had the number of children they wish. They are thus caught in a situation, where they both have to accept their HIV status and learn to live with it and have to consider the prospect of being responsible for raising a child, who is at severe risk of becoming orphaned and exposed to stigma and discrimination. The women's concerns about the negative impact HIV might have on their unborn child thus outweigh their wish of having a child (Bui et al. 2010). The occupational situation was the factor most strongly related to abortion. More specifically, women who worked as petty traders or independent labourers were more likely to have an abortion. An explanation for this finding may be that these women prioritized earning money to survive and were thus more likely to choose to terminate their pregnancy. A somewhat surprising finding was, however, that unemployed women tended to deliver. This may reflect the fact that unemployed women have a low status in their family, and as a number of studies have shown, they may feel pressured by their family members to have a child [Oosterhoff et al. 2008; Bui KC, Rasch V, Nguyen TTH & Gammeltort. Pregnancy decision-making among HIV-positive women in Northern Vietnam: Reconsidering reproductive choice (manuscript)]. Therefore, in this setting, having a low position in the family, might have led the women to satisfy the wishes of the others by continuing their pregnancy. The women's concerns related to pregnancy were found in the parallel qualitative study. The fear of a child's possibility of being HIV infected, stigma and discrimination and death, limited economic resources, their own bad health made women believe that they could not fulfil their maternal responsibilities as a mother (Bui et al. 2010). The decision of induced abortion had among the majority of women been made after consultations with family members such as husbands, parents-in-law or natal parents. These findings are in line with a parallel qualitative study that found that the women did not simply either submit to the others or made their "own" decision. The decision was often a complex process in which both husbands, natal parents and parents-in-law were involved [Bui KC, Rasch V, Nguyen TTH & Gammeltort. Pregnancy decision-making among HIV-positive women in Northern Vietnam: Reconsidering reproductive choice (manuscript)]. Our findings are linked to a number of studies where the influence of family members on pregnancy decision-making among HIV-positive women has been reported. For instance, another study from Vietnam found that the mothers-in-law pressured their daughters-in-law to have children to continue family's lineage (Oosterhoff et al. 2008). In conclusion, our study provides a profile of HIV-positive women who opted for an induced abortion after HIV diagnosis in Vietnam. Age, occupation and time of being diagnosed as HIV positive were found to be associated with induced abortion. To help women to make an informed reproductive choice, they should have a free access to PMTCT programs at the early stage of HIV infection, and the husband/partner's and family members' influence should be taken into consideration when providing counselling for HIV-positive women. We acknowledge the contribution of the women and the support of local authorities in Quang Ninh and Hai Phong. This work was conducted under ENRECA project, funded by the Danish International Development Assistance (Danida).