Scandinavian Journal of Public Health, 2006; 34: 414421

ORIGINAL ARTICLE

Perspectives of midwives and doctors on adolescent sexuality and abortion care in Vietnam

MARIE KLINGBERG-ALLVIN1,3, NGUYEN THU NGA2, ANNA-BERIT RANSJO 1,3,4 1 & ANNIKA JOHANSSON ARVIDSON
1

Department of Public Health Sciences, Division of International Health (IHCAR), Karolinska Institutet, Stockholm, gskolan Dalarna Falun, Sweden, Sweden, 2Uong Bi General Hospital, Vietnam, 3Faculty of Health and Social Science, Ho

and 4Department of Women and Child Health, Division of Reproductive and Perinatal Health Care, Karolinska Institutet, Stockholm, Sweden

Abstract Background: Vietnam has one of the highest abortion rates in the world and adolescent abortions are thought to constitute at least one-third of all cases. Lack of balanced reproductive health information and services to adolescents and negative social attitudes towards adolescent sexuality are contributing factors to the high abortion rates. Health providers are important in guiding and counselling adolescents on how to protect their reproductive health. There is a lack of studies on health providers perspectives on their work in adolescent reproductive health care. Aim: To explore the perspectives of midwives and doctors on adolescent sexuality and abortion, and what they considered to be quality abortion care for adolescents and the barriers to it, as well as to their own training needs. Methods: Observations of care in abortion clinics and focus-group discussions (FGD) were used to collect data. Doctors and midwives from three healthcare facilities in Quang Ninh province in Northern Vietnam participated in a total of eight FGDs. Data were analysed using latent content analysis. Findings: Major barriers identified for quality abortion care were of technical and managerial nature. Participants considered that counselling unmarried clients in connection with abortion should focus on warning against the risks and dangers of abortion and pre-marital sexual relations, which they strongly disapproved of. However, they also expressed a pragmatic and caring attitude towards the unmarried girls and couples coming for abortion. Adolescent sexuality and abortion are morally sensitive issues in the Vietnamese culture. The contradictions between cultural norms and the reality facing health providers while counselling unmarried adolescents need to be addressed in education and training programmes.

Key Words: Adolescent abortion, adolescent sexuality, counselling, nursing-midwifery education, Vietnam

Introduction Unprotected sex leading to unintended pregnancy, abortion, and increasing incidence of sexually transmitted infections, including HIV, among adolescents are major global public health problems [1,2]. Young peoples sexual behaviour reflects a changing society but health care services have been slow to develop realistic and relevant services for youth [3]. Societal norms condemning pre-marital sex often set barriers to rational decision-making and resource allocation and in many countries health services for adolescents are still grossly inadequate

and often not youth-friendly [4]. The World Health Organization (WHO) has identified the special problems of adolescents in contraception and abortion services and has emphasized the importance of high quality providerclient interaction in order to gain their confidence and assist them to protect their sexual and reproductive health [5]. Midwives are a core group of professionals who meet the special needs of adolescents within reproductive health services. The need to involve midwives and other mid-level providers has been recognized internationally; this to increase access to

Correspondence: Marie Klingberg-Allvin, Ho gskolan Dalarna 791 88 Falun, Sweden. Fax: + 46 23 77 80 80. E-mail: marie.klingberg@phs.ki.se (Accepted 19 October 2005) ISSN 1403-4948 print/ISSN 1651-1905 online/06/040414-8 # 2006 Taylor & Francis DOI: 10.1080/14034940500429046

Perspectives on adolescent sexuality and abortion care and improve the quality of abortion services for all women worldwide [6,7]). The aim of this study was to explore the perspective of midwives and doctors in relation to adolescent sexuality and abortion in Vietnam. The aim was further to identify what they considered to be quality abortion care for adolescents and any barriers to quality care found in their own setting, as well as to enhance the provision of quality care in their own training needs.

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7 weeks (49 days) of pregnancy. Between 12 and 18 weeks of gestation dilation and evacuation (D&E) is used to terminate a pregnancy [10]. According to the recent Vietnamese National Standards and Guidelines for Reproductive Health Care Services, women seeking abortion should be informed about contraceptive methods by a counsellor specially trained in contraceptive counselling [14].

The study Background The population of Vietnam is around 80 million, and young people 15 to 24 years constitute about 20% ([8]). After long periods of war and international isolation, Vietnam is experiencing rapid economic growth and sociodemographic change. Youth values and lifestyles are also changing and pre-marital sex is thought to be becoming more common. This is a sensitive issue in Vietnam, where Confucian morals strongly condemn pre-marital sexual relations [9]. Policy-makers and health managers in Vietnam are now addressing the responsibility of the health sector to protect adolescents reproductive health [10,11]. Study setting The study was conducted during March and April 2002 in Quang Ninh province in the north east of Vietnam. Quang Ninh, with a population of about one million, is a mixed ruralindustrial province with an important coal mining industry and a growing tourist industry in Ha Long Bay. The province has among the highest abortion and HIV rates in the country [15]. The study subjects were selected from three health facilities in Quang Ninh Province, two general hospitals and one Mother and Child Health (MCH) clinic. The clinic was chosen because it differed from the two other sites by participating in a project for the upgrading of abortion services, including the training of the staff in contraceptive counselling.

Abortion in Vietnam Legal abortion was introduced in Vietnam in 1945 as a right for women, but services were limited. Abortion became widely used in the 1980s in connection with the strictly implemented two-child policies [12]. As the choice of methods for many years was very limited (mainly IUDs and condoms) and services inadequate, abortion rates increased rapidly to reach levels that were among the highest worldwide [13]. Abortion rates among married women seem to have stabilized but a new phenomenon has appeared, i.e. increasing numbers of abortion among young, unmarried women. Currently within the public sector in Vietnam there are 7883 abortions per 1,000 women of reproductive age and health workers estimate that adolescent abortion constitutes about one-third of these [13]. The most commonly used method in Vietnam for termination of pregnancy from 2 to 12 gestational weeks is the manual vacuum aspiration (MVA), known as the menstrual regulation (MR) method if performed at up to 6 weeks of gestation. Dilatation and curettage (D&C) is still used in facilities lacking MVA, which is the preferred method. A medical abortion method, using mifepristone and misoprostole, was introduced in 2002 and may be used up to

Material and methods In order to get a general picture of the abortion services and the context. Informal observations were made by the first author (MK) at each setting included in the study (n-11). The findings were used in developing the thematic guide for the focus-group discussions (FGD), a qualitative method often used when sensitive topics are being explored [16]. The FGD guide raised issues related to pre-marital sexual relations and abortion and participant views on quality abortion care and barriers to this. In addition, each participant was asked to rank in writing what she/he considered to be the major components necessary for the provision of good quality abortion care. This open-ended question was presented at the beginning of the FGD and responded to individually. All staff at the clinics were informed about the aim and method of the study and were invited to participate in the discussions. A total number of 40 midwives (all women) and 28 doctors (including 2 men) volunteered to take part, which represented the large majority of all staff working at the abortion

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M. Klingberg-Allvin et al. research ethics committee at Karolinska Institute, Stockholm, Sweden.

clinics. They were divided by profession into eight groups with 610 participants in each. FGD participants ages ranged from 25 to 50 years with a mean age of 38 years. Almost all the participants were married and many had teenage children. The FGDs were held in a conference room at each facility, led by experienced Vietnamese moderators (mostly the second author NTN). On an average, a FGD lasted one and a half hours. The first author (MKA) participated as an observer in all eight sessions together with a translator. Field notes were taken during discussions, noting the interaction of the participants and the general atmosphere in the groups. All FGDs were tape-recorded. After each group discussion the research team met to discuss any unclear points and raised issues of special interest, which were then fed into the next FGD [16]. Data analysis The tape-recorded FGDs were transcribed in Vietnamese and translated into English by a professional translator. As the language structure of Vietnamese and English are very different, wordby-word translation is impossible and it may be difficult even for an experienced translator to capture the full meaning of the original text. To compensate for this, the research group spent considerable time comparing the translated transcripts with the original text and discussing its meaning. Latent content analysis was used to analyse data, an analytical method relevant for application to research problems regarding interaction of culture and social structures [17]. Two main categories were defined: (1) barriers to provision of quality abortion care, with the sub-categories lack of equipment, inconvenient services, creating confidence; and (2) values and attitudes towards premarital sexual relations and abortion. The subcategories here were disapproval of pre-marital sex, warning of dangers, and constraints in contraceptive use among adolescents. In the analysis we have attempted to identify emerging themes and tendencies and discuss their underlying meaning in a sociocultural context [17].

Results Findings from the observations conducted at the three abortion clinics are presented first, followed by the analysis of FGDs under the two main categories: (1) barriers to quality abortion care, and (2) values and attitudes towards adolescent sexuality and abortion. Observations at abortion clinics Women arrived early in the morning at the abortion clinics for registration and examination. The procedure was performed within one hour and took around 15 minutes. It was performed using MVA as the main method, but occasionally by the use of D&C. The most commonly used analgesic was Paracetamol in tablet form given prior to the abortion procedure, and a Para-cervical block (PCB) with local anaesthetics. An injection of morphine was given to women who were the last in the queue to have an abortion procedure, in order to substitute for local anaesthetics which were often used up at the end of the day. Observations at the clinic indicated that the women/clients were treated respectfully, but there was a lack of privacy. At the two hospital clinics, interaction between health care provider and client was minimal and dominated by one-way communication with the women answering questions. All women stayed at the clinic for post-abortion care (PAC) for about half an hour, but in reality few of them were examined or counselled. Few of them seemed to get any information about contraception, although the MCH clinic differed from the hospital clinics in that they provided private individual counselling to all women before abortion. Barriers to quality abortion care and counselling Asked to indicate the components necessary for the provision of high-quality abortion care and counselling, the aspects ranked highest by participants were in order of importance: (1) technically skilled providers who can conduct safe abortion procedures; (2) availability of standard equipment to perform a safe abortion; and (3) adequate provision of pain relief. These components were listed high by all, while aspects related to interpersonal communications, such as confidentiality, confidence, and counselling skills, were ranked lower.

Ethical consideration Participation was voluntary and participants were informed that all data would be analysed and presented group-wise to avoid individuals being recognized. Research permission was granted from the Ministry of Health in Hanoi, the Uong Bi General Hospital (UBGH) directorate and from the

Perspectives on adolescent sexuality and abortion care Lack of equipment. The main barrier to providing high-quality abortion care emerging from the FGDs was the lack of good equipment. Participants stated that they often had to use old equipment and techniques, such as curettage, which they felt were more painful for the women than MVA. They stressed the fact that the poor access to new equipment was a risk factor for unsafe abortion. Participants also raised the problem of insufficient quantities of pain-relief drugs, the high cost of pain relief, which could be prohibitive for poor women, and the need for new methods of pain relief in abortion services. Inconvenient services. Other than technical shortcomings, some of the initial barriers identified by participants were the long waiting times due to very detailed medical record taking. This was considered a general problem but acted as a barrier particularly for adolescent clients, as they were concerned about the need to remain anonymous and had a desire for the abortion procedure to be completed as quickly as possible. It was suggested that in order to attract more adolescent clients from the private clinics, waiting time at the public clinics should be reduced and the administrative procedures simplified. The importance of providing friendly initial reception and sufficient time to make the clients feel confident was stressed, particularly by the group of midwives from the MCH clinic. The lack of privacy at public clinics was seen as prohibitive for adolescent clients and was believed to make many of them choose private clinics instead. Creating confidence. It was evident from the observations and the comments of participants that counselling in connection with the abortion at the two hospital clinics was very limited and, thus, found to be unsatisfactory. There was consensus in the groups that this should ideally be given in a separate room with one client at a time. It was suggested that group counselling, gathering several clients with similar problems, could be an alternative method. Clients with similar problems, especially adolescent girls or couples, could then share experiences and support each other. Counselling with the womans partner present was thought to be the best counselling situation. However, the real situation at both hospital clinics was far from the ideal. Other than privacy and suitable arrangements, the central aspect that emerged in the groups when discussing counselling for unmarried youth was how to create trust and confidence:

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The young people who come to us are normally shy, we need to respect their feelings and gradually find out reasons for the pregnancy. We can then discuss and advise them about contraception. But their secret should be kept safe. The time aspect was repeatedly brought up in the discussions about counselling, as shown in this group of midwives: We need time when we counsel our clients because we have to talk to them individually. For a Vietnamese it is very difficult to confide in a person you dont know well, especially when it comes to such personal matters. Therefore, time is an important factor but in most cases we have very little time. Other than time constraints, lack of communication skills and technical knowledge related to contraceptive advice were also brought up as barriers to good counselling. Below are excerpts from discussions among doctors: The problem is not only the lack of time. We do not know how to give effective counselling. How can we advise our clients when we dont have sufficient knowledge of modern contraceptive methods ourselves? In a group of doctors, it was questioned whether counselling was indeed part of their tasks in the abortion clinic: In fact, doctors and midwives are busy with professional tasks, which give us little time to give detailed counselling.

Values and attitudes towards adolescent sexuality and abortion Disapproval of pre-marital sex. Attitudes towards premarital sexual relations were characterized by strong disapproval. Youth leading a healthy lifestyle observed sexual abstinence before marriage, while its opposite, an unhealthy lifestyle, was characterized by pre-marital sex, often leading to school dropout and possibly linked to social evils such as prostitution and gambling. Some hospital midwives suggested that the best thing would be to forbid pre-marital sexual relations altogether. The only slightly diverging views came from a group of doctors who said that as sexuality is a normal part

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M. Klingberg-Allvin et al. Constraints in contraceptive use among adolescents. In discussing suitable contraceptives for adolescents, opinions varied from no sex is the best contraceptive to more or less restrictive opinions on suitable methods. Some methods were said to be good as such, but not suitable for the unmarried as they will lead to more sex; others were thought to be a health risk for young women. The IUD was considered to be a good contraceptive method but only for married women as the unmarried were thought to have more sex if they had an IUD inserted. Some considered the contraceptive pill to be unsuitable for adolescent girls, partly because of its perceived negative effect on their future fertility and health (it was thought by some to cause cancer), partly because of inciting the girls to have more sex. Others thought the pill might be a good alternative for adolescents, but they were aware that unmarried girls felt the pill to be inconvenient, since they needed to remember to take it every day, and that it was difficult to hide from inquisitive parents. A tendency in all FGDs was that the condom was the most suitable contraceptive for adolescents as it prevents not only unplanned pregnancies but also HIV and STD. But participants were aware that the use of condom was problematic. Several of them had met young women coming for abortion who had intended to use condoms but their boyfriend did not approve. The emergency contraceptive pill (ECP) is fairly new in Vietnam but was mentioned as a suitable method for adolescents who have an irregular sex life. Opinions about how to use the ECP were divided; some thought it was not good for regular usage while others thought it could be taken up to four times a month or more. Participants stressed that most providers, including themselves, lack sufficient knowledge of modern contraceptive methods. Discussion A tendency emerging from the analysis was the emphasis on the technical and managerial improvement needed for high-quality abortion care, such as shorter waiting time, less complicated managerial procedures, and better equipment and pain relief. Counselling was discussed mainly in terms of the many existing constraints, notably the lack of time. Other studies in Vietnam have confirmed that counselling time in connection with abortion and other reproductive health services is usually very short, or totally non-existent [10,18,19]. The statement from a doctors group in our study that the providers are too busy with professional tasks to

of development open communication about it would be beneficial. But even for those, the moral stance was clearly that it is preferable to avoid sexual relations before marriage. Warning of the dangers. As health professionals, participants felt that it was their task in counselling to warn their unmarried clients of the risks and danger of both pre-marital sex and abortion. In particular, midwives from the two hospitals stressed this aspect: I think that first we should inform our clients about the risks of having pre-marital sex, then about abortion and its bad effects on their health and later fertility. Pre-marital sex also affects their studies. Adolescents should have a clear and healthy love, meaning avoiding pre-marital sex if they are not ready to marry. Despite the strongly disapproving attitudes towards pre-marital sex, there was a tendency among both doctors and midwives to deal pragmatically with the problems of their young abortion clients: Generally speaking, we cannot blame young people for having sex early because it is the modern trend in society. However, we need to provide adolescents with sexual and reproductive information. What exactly the information should be about was a point of contention in the FGDs. Some maintained teaching good morals first, stressing the value of chastity before marriage to ensure a happy married life. Others were more inclined to advocate that adolescents should be taught what contraceptives are suitable for them and where to access them. Education and information to adolescents should be given by society, i.e. youth unions, schools, parents, etc. As health care providers at abortion clinics, they felt that their main responsibility was, other than providing a safe abortion, to warn the young women, and preferably the couples, of the dangers of abortion as a way to make them avoid an unwanted pregnancy in the future. One group of midwives explained how this was done: We often make use of their boyfriends presence to show how hurt their girlfriends are after abortion and to explain to them about complications and risks of abortion in order to frighten them.

Perspectives on adolescent sexuality and abortion care be able to devote time to counselling is an expression of the low priority attached to this component in the Vietnamese reproductive health services. But there was a strong awareness among many participants of the need for improved counselling and for more training of providers in counselling skills. With regard to the content of counselling, a major theme emerging from the FGDs was that of the risk and danger associated with pre-marital relations and abortion. The danger of pre-marital sex was expressed in the general idioms of the dominant moral climate of contemporary Vietnam, i.e. as unhealthy, bad for studies, with negative repercussions for future happiness in marriage, etc. Other research from Vietnam confirms that premarital sex is still strongly condemned and even considered as a degradation of Vietnamese culture. The purity of youth is often seen as a symbol of the purity of the country, the culture and young women in particular are considered as guardians of traditional moral values [9]. Thus, the attitudes among the FGD participants towards adolescent sexuality can be seen as a worry not only regarding individual behaviour and risk-taking but also regarding the dangers of disintegration of traditional moral values and cultural identity. The mean age of the participants in this study was 37 years. Interestingly, findings from our study among midwifery students in Vietnam showed that most of the students, whose mean age was just over 20, also were strictly against pre-marital sex, indicating the strength of this deep cultural norm [20]. Labelling pre-marital sexual relations as risk taking behaviour is a common perspective in societies where traditional values and moral strictures against such relations prevail [21]. As in our study, risk and danger and disapproving attitudes are the dominant messages reaching adolescents in many countries when their sexuality is at stake, whether in the family, at school, or in their contacts with the health services. For example, one study from Ghana revealed how providers restricted the access of unmarried young people to reproductive healthcare, arguing that this was done in order to protect their culture and preserve traditional values [22]. It is hardly surprising that health care providers advise the unmarried against pre-marital sex in situations where such behaviour is subject to strong societal condemnation and tend to victimize the girls. But it is extremely unfortunate if this means restricted access of the adolescents to the reproductive health services they need, exposing them to serious health hazards. Another moral dilemma facing the health providers is the abortion per se. In view of the fact that

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Vietnam today has one of the highest abortion rates globally [13], the generally negative view of the health providers towards abortion is problematic, if not surprising. Induced abortion became increasingly common in Vietnam starting in the 1980s in the context of the governments two-child policy. Preoccupied with the rising birth rates, the government greatly expanded contraceptive as well as abortion services, and abortion rates soon reached levels comparable to those in the former Soviet Union [23]. Unlike in the Soviet society, where abortion has existed for decades and has met with little ideological or moral opposition [24], the abortion culture that has developed during the last two decades in Vietnam seems to have been fraught with moral doubt. In the Buddhist religion, the view on induced abortion is not clearly defined in sacred texts [25], but according to lay Buddhist ethics in Vietnam, abortion was previously seen as killing a human life and was considered a severe sin [12]. Evidence of this is found in a study based on interviews with young abortion clients in Hanoi. For menstrual regulation before week 6 to 8, the foetus was described as just a clot of blood, while for a later abortion the young clients felt moral doubt and sometimes anguish. They also feared that their future fertility would be compromised [26]. In most societies, the decision to have an abortion carries strong moral weight, and few issues stir more controversy, especially if there is no open dialogue around it. If those who are charged with providing abortion services themselves have unresolved moral doubts towards abortion, the messages to clients may be contradictory, stressing its dangers rather than supporting clients to make rational choices. The Vietnamese National Standards and Guidelines for Reproductive Health Care Services underline the importance of providing adolescents with supportive and non-judgemental reproductive health and abortion counselling [14]. For this to materialize, we believe that there is need in education and training programmes at all levels for dialogue and reflection on both pre-marital sexuality and abortion. The current emphasis in such programmes is on medical and technical aspects, while there is little attention to the moral, social, and gender aspects of sexuality and reproductive health. International studies have shown that training health care providers in communication skills, including value clarification on adolescent sexuality and gender, remarkably improves the quality of care and counselling given to adolescents clients [27,28]. In conclusion, it is evident that the counselling task of health providers in adolescent reproductive

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M. Klingberg-Allvin et al. References

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health services in Vietnam is a delicate and complicated one, which needs recognition. The contradiction between cultural norms and actual practice is rarely more acute than when the young generation challenges one of the deepest cultural values: the virginity of its young women. Acknowledgement of the cultural and societal context of the health care providers is basic for understanding their attitudes and practice. We suggest that value clarification in education and inservice training programmes would help students and providers reflect on their own attitudes and moral values in relation to adolescent sexuality and its consequences. This would give them a better platform as professionals to face the challenges of adolescent reproductive health and rights in the rapidly changing sociocultural environment of Vietnam today. Limitations of the study Focus-group discussions are considered the method of choice for exploring peoples opinions, views, and attitudes regarding a certain topic in an interactive setting, which capture how views are constructed and expressed [16]. On the whole our focus-group discussions were very lively and carried out in a friendly atmosphere. We had deliberately composed the groups to avoid hierarchical relations (doctors and midwives separately) and interaction seemed easy. However, as is common in the Vietnamese culture, the older participants tended to take the lead in the discussions, possibly bending these towards more traditional views. Only two male participants were included in the FGD, both young and not very talkative. Thus, our findings represent mainly female perspectives. Research on male attitudes and among younger health providers would complement the findings of this study. Acknowledgements The authors wish to thank the midwives and doctors who shared their views with them in an open and friendly way. They also thank the managers of the three study sites who kindly helped to organize the FGDs. Vu Pham Nguyen Thanh was of valuable help in discussion on the FGD guide and training the moderator. The first author is funded as a research student by The Health Care Sciences Postgraduate School at Karolinska Institute, Sweden. A Minor Field Study Grant made the study possible, funded by Sida through Ho gskolan Dalarna, which is gratefully acknowledged.

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[26] Gammeltoft T. Between Science and superstition: moral perceptions and induced abortion among young adults in Vietnam. Cult, Med Psychiatry 2002;26:31338. [27] Miller S, Billings D, Clifford B. Midwives and post abortion care: Experiences, opinions, and attitudes among participants at the 25th triennial congress of the international confederation of midwives. J Midwifery Woman Health 2002;4:24755. [28] Kohler R, Nelson D, Sebikali B. Improving clientprovider interaction and counselling. Results Review II/2001(PRIME PAGES: RR8).