International Journal of Gynecology and Obstetrics 125 (2014) 241–246
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CLINICAL ARTICLE
Risk factors for repeat abortion and implications for addressing unintended pregnancy in Vietnam Thoai D. Ngo a,b,⁎, Sarah Keogh b, Thang H. Nguyen c, Hoan T. Le d, Kiet H.T. Pham e, Yen B.T. Nguyen e a
Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK Research, Monitoring and Evaluation Team, Health System Department, Marie Stopes International, London, UK Research and Metrics Team, Marie Stopes International Vietnam, Hanoi, Vietnam d Department of Environmental Health, Hanoi Medical University, Hanoi, Vietnam e Department of Health Economics, Hanoi Medical University, Hanoi, Vietnam b c
a r t i c l e
i n f o
Article history: Received 19 July 2013 Received in revised form 1 November 2013 Accepted 25 February 2014 Keywords: Post-abortion family planning Repeat abortion Reproductive health Sex imbalance Unmet need Vietnam
a b s t r a c t Objective: To determine predictors of repeat abortion in 3 provinces in Vietnam. Methods: In a cross-sectional study between August and December 2011, women who underwent abortion were interviewed after the procedure in 62 public health facilities in Hanoi, Khanh Hoa, and Ho Chi Minh City (HCMC). Information on sociodemographic factors, contraceptive and reproductive history and intentions, and opinions and experience of abortion services was collected. The primary outcome was repeat (≥ 2) abortions. Results: Overall, 1224 women were interviewed: 534 from Hanoi, 163 from Khanh Hoa, and 527 from HCMC. The mean age and parity of the respondents were 29 years and 1.8, respectively, and 79.6% were married. Approximately half of the respondents were not using contraception before pregnancy. The prevalence of repeat abortion was 31.7%. In multivariate models, significant predictors of repeat abortion included living in Hanoi, higher parity, age 35 years or older, and having 2 or more daughters (versus 1) or no sons (versus 1) after controlling for parity (all P b 0.05). Conclusion: Repeat abortion remains high in Vietnam, fueled partly by inadequate contraceptive use. Son preference seems to be an important predictor of repeat abortion. Strengthening post-abortion contraceptive counseling and promoting long-acting contraceptive methods are essential to reduce repeat abortion. © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Vietnam has one of the highest abortion rates in the world, estimated at 26 abortions per 1000 women in 2007 [1]. Despite Vietnam’s liberal abortion law, unsafe abortion contributed to an estimated 11.5% of maternal deaths in 2000–2001 [2]. Vietnam’s abortion rate equates to 2.5 abortions per woman per lifetime, indicating a high level of repeat abortion. This is despite a high prevalence of contraceptive use of 78% among married women [3]. Abortion among young Vietnamese women is also increasing: in Ho Chi Minh City (HCMC), the number of abortions among females aged 10–24 years increased from 781 in 2005 to 2235 in 2007 [4,5]. Vietnam’s contraceptive provision is skewed toward the intrauterine device (IUD), which, particularly among young women, is not always the preferred contraceptive method. High rates of IUD discontinuation for method-related reasons have been documented in Vietnam, which
⁎ Corresponding author at: London School of Hygiene & Tropical Medicine and Research, Monitoring and Evaluation Team, Health System Department, Marie Stopes International, 1 Conway Street, London W1T 6LP, UK. Tel.: +44 78 8741 4504; fax: +44 20 7034 2372. E-mail address: [email protected] (T.D. Ngo).
might potentially contribute to the country’s high abortion rate [6]. Whereas 1 abortion is indicative of unintended pregnancy, repeat abortion might signify a need for improvement in family planning programs to support women presenting for terminations in adopting—and continuing on—a contraceptive method of their choice [7]. Vietnam’s sex ratio at birth increased from 106 male births per 100 female births in 2000 to 112 male births in 2008 [8–10]. Prenatal sex diagnosis and sex selection practices are prohibited in Vietnam [8]; however, it has been suggested that affordable sex determination technology has allowed Vietnamese couples to pursue their desire for 1 or more sons, thereby fuelling the high rate of abortion [8,11]. Studies in high-income countries have identified common risk factors for repeat abortion such as older age, high parity, and lower socioeconomic status [12–14]. Despite the high rate of repeat abortion in Vietnam, only 1 qualitative study has examined the characteristics of women undergoing repeat abortion in the country, and it found no sociodemographic factors associated with repeat abortion [15]. Identification of risk factors for repeat abortion might help family planning programs to design health interventions that improve contraceptive adoption and continuation subsequent to a woman’s first abortion. To address this research gap in Vietnam, the aim of the present study was to explore risk factors associated with repeat abortion among
http://dx.doi.org/10.1016/j.ijgo.2013.11.014 0020-7292/© 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
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women presenting for termination services at public health facilities in Hanoi, Khanh Hoa, and HCMC, Vietnam.
associated with repeat abortion at the bivariate or multivariate level were considered to be predictors and were included in the final model. 3. Results
2. Materials and methods The present cross-sectional exit interview survey was conducted among women receiving termination services at selected public health facilities in Hanoi municipality, HCMC municipality, and Khanh Hoa Province between August 1 and December 31, 2011. Ethical approval for the study was provided from the institutional review boards at the London School of Hygiene and Tropical Medicine and Hanoi School of Public Health, and all participants provided written informed consent before the interview. A multistage sampling strategy was implemented to select the areas, health facilities, and women. The 3 areas were selected to represent geographic and cultural differences within the country (north, south, and central, respectively). The following public health facility levels were included: central specialist and general hospitals; provincial specialist and general hospitals or reproductive health centers (RHCs); and district hospitals or RHCs. A master list of all health facilities in the 3 regions was obtained from the municipal and provincial departments of health. All specialist hospitals and RHCs specializing only in sexual and reproductive health service provision were selected, owing to the limited numbers of these facilities at each health administrative level. A random sampling strategy was used to select 50% of all nonspecialized facilities (general hospitals and commune health stations). In total, 62 health facilities were included. This sampling method was previously described [16]. All women presenting for termination services at these facilities and living in the province or municipality in which the health facility was located were eligible for inclusion. Subsequent to the procedure and counseling session, women were invited to participate in a structured face-to-face exit interview. The interview questionnaire was developed in English, translated into Vietnamese, revised after a pilot study, and back-translated into English. The questionnaire collected information on sociodemographic characteristics, abortion knowledge and attitudes, reproductive and contraceptive history, abortion experience, contraceptive and childbearing intentions, and knowledge and perceptions of abortion services. Statistical analyses were performed via Stata version 11.1 (StataCorp, College Station, TX, USA). Owing to the multistage sampling strategy of the study design, with respondents selected within facilities, all statistical analyses took clustering into account via the Stata survey (svy) commands. Because the proportion of sampled facilities differed according to the facility type, respondents attending general health facilities had half the probability of selection as those attending specialized facilities, and were thus given twice the weight of women attending specialized facilities in the analyses. Although the sample was not nationally representative, the study design ensured that it was representative of Hanoi, Khanh Hoa, and HCMC. Descriptive analyses were carried out to show the distribution of sociodemographic, reproductive, and abortion-related characteristics both overall and for first-time versus repeat abortion groups. The distribution of contraceptive methods (past use, intended use, and reasons for non-use) and barriers to accessing abortion were examined in a similar manner. A P value of less than 0.05 was considered to be statistically significant. Bivariate and multivariate logistic regression models were used to determine predictors of repeat abortion. Variables considered as potential predictors included sociodemographic characteristics, reproductive and contraceptive history, reproductive and contraceptive intentions, abortion characteristics (gestational age and type of abortion), and factors related to abortion service access (cost, distance, and perceived accessibility). Whether number of sons and/or daughters was predictive of repeat abortion was also tested. Only factors that were significantly
During the study period, 1224 women completed the survey: 534 from Hanoi, 163 from Khanh Hoa, and 527 from HCMC. This represented a 99.7% response rate. The mean age of respondents was 28.8 years. More than 50% were aged 20–30 years, approximately 43% were aged over 30 years, and 6.2% were younger than 20 years. Almost 80% of respondents were married, and 58.1% had at least high school education (8.8% had primary level or no education). Approximately one-third of respondents had no children, and 7.4% had more than 2 children. Half of the respondents were using contraception before the recent pregnancy, and most (86.5%) expressed their intention to use contraception after the abortion. Almost 43% of respondents wanted to stop childbearing, and 18.1% intended to have a child within 2 years (Table 1). The prevalence of repeat abortion, defined as 2 or more abortions, was 31.7%. Women undergoing repeat abortion were similar to those undergoing first-time abortion in terms of educational attainment, distance traveled to clinic, and gestational age. Among all women, gestational age at the time of termination ranged from 0 to 29 weeks (52.3% at 5–6 weeks, and 6.4% at ≥9 weeks). Only 32 respondents (or 2.6% of the total sample) were in their second trimester. Compared with those undergoing first-time abortion, those undergoing repeat abortion were more likely to be married (90.0% vs 75.0%; P ≤ 0.001) and from Hanoi (50.5% vs 34.7%; P = 0.016). They were also older (P ≤ 0.001) with higher parity (P ≤ 0.001), and were more likely to want to stop childbearing than women undergoing first-time abortion (63.6% vs 33.7%; P ≤ 0.001). They were also more likely to have a surgical (rather than medical) abortion compared with women in the firsttime abortion group (85.5% vs 72.7%; P = 0.030). Among the respondents, condoms were the most popular contraceptive method, followed by the pill and emergency contraception (Fig. 1); there were no significant differences between first-time and repeat abortion. When asked about the reasons for non-use of contraceptives, women in the first-time abortion group were more likely than those in the repeat abortion group to cite lack of contraceptive knowledge (23.4% vs 12.4%; P = 0.039), but less likely to cite partner disapproval (21.2% vs 28.3%; P = 0.020). With regard to contraceptive intentions subsequent to the abortion, the pill (37.8%) and condoms (35.5%) remained the most popular methods, followed by the IUD (27.4%). Intention to use condoms was significantly lower among women undergoing repeat abortion than among those undergoing first-time abortion (27.1% vs 39.9%; P ≤ 0.001), in contrast to past condom use (Fig. 1). There was a significant association between repeat abortion and intention to adopt user-independent methods (sterilization, IUD, and injectables) versus user-dependent methods (condoms, pill, emergency contraception, periodic abstinence, and withdrawal) (P = 0.034). Overall, 34.4% of women undergoing repeat abortion expressed the intention to adopt only user-independent methods, compared with 26.3% of women undergoing first-time abortion. By contrast, 68.7% of women in the first-time abortion group intended to use only user-dependent methods, compared with 56.6% of women in the repeat abortion group. Most women undergoing both first-time (75.9%) and repeat (81.6%) abortion thought that abortion services were accessible in their area of residence. Each of the main barriers to accessing abortion services (lack of knowledge, cost, distance, and reluctance to use a public provider) was cited by 10% or less of respondents in both groups (Fig. 2). Stigma seemed to be a far greater barrier in the first-time abortion group than in the repeat abortion group (17.5% vs 7.0%; P = 0.012). The proportion of respondents citing each barrier to accessing abortion was between 2 and 17 times higher in Khanh Hoa than in the other regions. For instance, 30.2% of respondents in Khanh Hoa said that they
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Table 1 Characteristics of women stratified by repeat and first-time abortion. Characteristics Socio-demographic Age group, y 14–19 20–24 25–29 30–34 ≥35 Region Hanoi Khanh Hoa HCMC Marital status Single Married Living with partner Educational attainment None/primary Secondary High school/technical College/uni/postgrad Number of children 0 1 2 3–8 Number of sons 0 1 2–4 Number of daughters 0 1 2–4 Abortion-related Was using FP before this pregnancy Type of procedure today Surgical abortion Medical abortion Distance traveled from home, km b5 5–9 10–19 ≥20 Gestational age at abortion, wk ≤4 5–6 7–9 ≥9 Reproductive intentions Childbearing desires No more children Child within 2 y Child after 2 y Doesn’t know Wants to use FP after abortion? Yes No Doesn’t know
Overall sample (n = 1224)
First-time abortion group (n = 818)
Repeat abortion group (n = 406)
P valuea
6.2 27.3 23.7 19.1 23.6
8.5 33.7 24.7 17.1 16.1
1.3 13.7 21.6 23.5 39.9
≤0.001
39.8 10.4 49.8
34.7 11.9 53.3
50.5 7.2 42.3
0.016
17.1 79.6 3.3
21.6 75.0 3.4
7.2 90.0 2.8
≤0.001
8.8 33.1 36.1 22.0
8.1 32.3 36.6 23.0
10.4 34.8 35.1 19.7
0.457
30.7 24.9 37.1 7.4
39.0 27.6 27.6 5.8
12.7 19.0 57.6 10.7
≤0.001
49.4 37.6 13.0
58.4 31.7 9.9
31.1 49.4 19.5
≤0.001
57.8 32.2 10.0
64.3 29.1 6.6
44.8 38.6 16.7
≤0.001
50.3
48.0
55.2
0.075
76.8 23.2
72.7 27.3
85.5 14.5
0.030
30.7 30.8 24.9 13.6
29.6 30.2 25.6 14.6
33.0 32.3 23.2 11.5
0.624
17.1 52.3 24.2 6.4
16.2 52.1 24.5 7.2
18.9 53.2 23.3 4.6
0.210
42.9 18.1 28.3 10.7
33.7 19.9 34.1 12.3
63.6 13.9 15.3 7.2
≤0.001
86.5 11.4 2.2
85.4 12.7 1.9
88.9 8.4 2.7
0.341
Abbreviation: FP, family planning. Values are given as a percentage unless stated otherwise.
a
would prefer a private provider, compared with 6.1% in Hanoi and 2.4% in HCMC (P ≤ 0.001). Stigma was cited by a significantly higher proportion of respondents in both Khanh Hoa (43.6%) and HCMC (12.2%) than in Hanoi (5.6%; P ≤ 0.001). In bivariate analyses, the odds of repeat abortion were significantly lower in Khanh Hoa (odds ratio [OR] 0.41; 95% confidence interval [CI], 0.27–0.64; P = 0.004) and HCMC (OR 0.54; 95% CI, 0.33–0.90; P = 0.027) than in Hanoi, and increased significantly with age (P ≤ 0.001) and parity (P = 0.002). Being single (P ≤ 0.001), having no daughters (versus 1) (P = 0.008), and having no sons (versus 1) (P ≤ 0.001) were associated with lower odds of repeat abortion. By contrast,
having several daughters (versus 1) (OR 1.78; 95% CI, 1.13–2.81; P = 0.023) significantly increased the odds of repeat abortion. To examine the overall effect of the sex distribution of children, parity by sex composition (hereafter “parity–sex”) was examined. Using the reference category of “1 son and 1 daughter,” the odds of repeat abortion were still significantly lower for women who had 0 sons and 0 (P ≤ 0.001) or 1 daughter (P = 0.006), and women who had 0 daughters and 1 son (P = 0.020). However, unlike in the previous regression, which used number of daughters instead of the parity–sex variable, the odds of repeat abortion for women with 2–4 daughters (P = 0.747) were not significantly higher than the reference category. This was
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Fig. 1. Proportion of women who used contraceptives before the pregnancy and who intend to use in future, for first and repeat abortion clients.
due either to smaller cell sizes in the narrowly defined parity–sex categories (leading to decreased significance) or to the particular choice of reference category, which obscures the broader effects of the number of daughters on repeat abortion when “number of sons” categories are combined. The odds of repeat abortion were significantly lower among women who wanted more children (P ≤ 0.001) or were unsure than among women who wanted to stop childbearing (P = 0.002). In a multivariate analysis controlling for sociodemographic characteristics (region, age, marital status, and number of children), repeat abortion was no longer associated with childbearing desire or marital status. The direction of association with age and parity remained the same but decreased in strength. Having 0 sons (versus 1) significantly decreased the odds of repeat abortion (OR, 0.41; P = 0.009), whereas having several daughters (versus 1) increased the odds nearly 3-fold (OR, 2.94; P ≤ 0.001). Having 0 daughters (versus 1) was no longer associated with lower odds of repeat abortion, indicating that this association was explained by parity. This was confirmed in a regression using the parity–sex variable instead of parity: compared with women with 1 son and 1 daughter (the reference category), the odds of repeat abortion were significantly lower for women who had 0 sons, and 0 or 1 daughter (P ≤ 0.001 and P = 0.015, respectively). Unlike in the previous regression, which used number of daughters instead of the parity–sex variable, having 2–4 daughters was not associated with a significantly higher odds of repeat abortion compared with the reference category. The regression using number of daughters instead of the parity–sex
variable showed that when the analysis controlled for the number of sons, having 2–4 daughters compared with 1 daughter significantly increased the odds of repeat abortion. The odds of repeat abortion remained lower in Khanh Hoa (OR, 0.45; P = 0.039) and HCMC (OR, 0.56; P = 0.042) than in Hanoi. There were no significant differences between the first-time and repeat abortion groups in reported cost and distance to clinic, or in the proportion of women who said that abortion services were accessible; inclusion of these variables in the multivariate model did not alter the association between region and repeat abortion (Table 2). 4. Discussion In the present survey of Hanoi, HCMC, and Khanh Hoa Province in Vietnam, approximately one-third of abortion-seeking women had had a repeat abortion (31.7%). This figure is higher than that found in a study in Thai Nguyen Province, which documented a prevalence of 11.5% [16], but is similar to or lower than estimates in both lowresource (32.3% in Nepal [17]) and high-resource (30%–38% in northern Europe [18] and 48% in the United States [17]) settings. The prevalence of repeat abortion among unmarried women was much lower in the present survey than in China (7% vs 33%), a country that is socioculturally similar to Vietnam [13]. In the present study, risk factors for repeat abortion included region (Hanoi), higher parity, age 35 years or older, and 2 or more daughters (versus 1) or 0 sons (versus 1). Studies in Nepal, Europe, and the
Fig. 2. Proportion of women citing the following barriers to accessing abortion, for first-time and repeat abortion clients.
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Table 2 Predictors of repeat abortion. Variable Socio-demographic characteristics Region Hanoi Khanh Hoa HCMC Age group, y 14–19 20–24 25–29 30–34 ≥35 Marital status Single Married Living with partner Number of children 0 1 2 3–8 Other characteristics Number of sons 0 1 2–4 Number of daughters 0 1 2–4 Parity by sex compositionb 0 sons, 0 daughters 0 sons, 1 daughter 0 sons, 2–4 daughters 1 son, 0 daughters 1 son, 1 daughter 1 son, 2–4 daughters 2–4 sons, 0 daughters 2–4 sons, 1 daughter 2–4 sons, 2–4 daughters Childbearing desires No more Within 2 y After 2 y Doesn’t know
Crude OR (95% CI)
1.00 0.41 (0.27–0.64) 0.54 (0.33–0.90) 0.37 (0.18–0.86) 1.00 2.15 (1.41–3.29) 3.38 (2.56–4.46) 6.12 (4.26–8.78)
P value
0.004 0.027 0.028 0.006 ≤0.001 ≤0.001
0.27 (0.17–0.45) 1.00 0.69 (0.21–2.21)
≤0.001
0.47 (0.30–0.75) 1.00 3.03 (1.80–5.11) 2.66 (1.78–3.98)
0.008
0.35 (0.30–0.40) 1.00 1.22 (0.98–1.53)
≤0.001
0.52 (0.35–0.77) 1.00 1.78 (1.13–2.81)
0.008
0.16 (0.12–0.20) 0.21 (0.08–0.50) 1.14 (0.57–2.25) 0.45 (0.24–0.82) 1.00 1.29 (0.57–2.92) 0.94 (0.58–1.52) 0.76 (0.23–2.48) 1.05 (0.73–1.50)
≤0.001 0.006 0.649 0.020
1.00 0.37 (0.27–0.50) 0.24 (0.18–0.32) 0.31 (0.19–0.50)
0.445
0.003 0.002
0.068
0.023
Adjusted OR (95% CI)a
1.00 0.45 (0.21–0.94) 0.56 (0.33–0.97)
P value for adjusted OR
0.039 0.042
0.46 (0.17–1.24) 1.00 1.50 (0.79–2.83) 1.72 (0.99–3.01) 3.05 (1.65–5.65)
0.101
1.24 (0.61–2.50) 1.00 3.08 (0.82–11.58)
0.469
0.62 (0.27–1.43) 1.00 2.18 (1.33–3.58) 1.75 (0.88–3.47)
0.201
0.41 (0.23–0.71) 1.00 1.32 (0.80–2.18)
0.009
0.77 (0.35–1.71) 1.00 2.94 (1.93–4.47)
0.444
0.465 0.741 0.581 0.747
0.29 (0.19–0.45) 0.29 (0.12–0.70) 1.17 (0.54–2.52) 0.63 (0.33–1.20) 1.00 1.20 (0.52–2.76) 0.95 (0.58–1.53) 0.78 (0.18–3.44) 1.00 (0.45–2.26)
≤0.001 ≤0.001 0.002
1.00 1.16 (0.63–2.15) 0.94 (0.53–1.67) 1.03 (0.53–2.02)
0.163 0.054 0.006
0.080
0.010 0.092
0.219
≤0.001 ≤0.001 0.015 0.621 0.126 0.608 0.778 0.690 0.991
0.555 0.798 0.900
Abbreviations: CI, confidence interval; HCMC, Ho Chi Minh City; OR, odds ratio. a Adjusted for socio-demographic characteristics. b Not adjusted for parity owing to endogeneity of the 2 variables.
United States have also reported age and parity as important predictors of repeat abortion [19–21]. Whereas surveys in Europe and the United States have highlighted low education or income as predictors of repeat abortion, socioeconomic status did not emerge as a predictor in the present analysis. Previous studies have proposed correlations in Vietnam among son preference, the high abortion rate, and the sex ratio imbalance at birth [10,22]. The present findings suggest that preference for a son is associated with a higher likelihood of having a repeat abortion. Women with 0 sons were significantly less likely to have a repeat abortion than those with 1 son. This is consistent with a previous study showing that Vietnamese couples stop childbearing after they have had 1 son [9]. The present findings and those of others suggest that Vietnam’s “1–2” child policy and son preference both have a potential effect on the country’s repeat abortion rate. Although the Vietnamese cultural preference for sons would be difficult to address through health interventions, the “1–2” child policy might be revisited to reflect the country’s commitment to promotion of healthy family planning. The present findings showed that Vietnamese women presenting for abortion relied heavily on user-dependent contraceptives. In contrast to the general female population of reproductive age in Vietnam, among
whom the IUD is used by 51.2% of married women [23], women undergoing repeat abortion in the present survey (90% of whom were married) used less effective methods such as contraceptive pills and condoms. The repeat abortion group also had a higher percentage of past use of condoms compared with the first-time abortion group, suggesting that these women prefer short-term methods and adopt reactive rather than proactive contraceptive behavior. Women who had a repeat abortion were more likely to consider user-independent methods for the future, suggesting that repeat abortion might serve as an incentive to start using a more effective method. This highlights the need for Vietnam’s family planning program to expand its range of long-acting reversible contraceptives by making implants available and accessible in conjunction with IUDs. In the repeat abortion group, the main barrier to contraceptive use was partner disapproval. To adequately prevent repeat abortion caused by unintended pregnancy, targeted interventions are required through Vietnam’s family planning program to actively engage men in reproductive health education programs. The present study involved a large cross-sectional survey of abortionseeking women across 3 regions in Vietnam. It does, however, have some limitations. Although the sampling design enabled the data to be
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more representative of the general population of abortion-seeking women in Vietnam, the regions selected include more established municipalities and provinces that might not be representative of smaller provinces in rural areas. Previous studies have suggested that alcohol or drug use and gender-based violence might be predictors of repeat abortion [16,21,22,24]; however, information on these factors was not collected in the present survey. Stigma emerged as an important barrier to accessing abortion services in the present study but, owing to the nature of the quantitative survey, it was not possible to investigate the nature of this stigma in any depth. There is a need for improvement in Vietnam’s national family planning program to address the disconnection between the high repeat abortion rate and the high prevalence of contraceptive use. Further research and program efforts are required to understand the barriers to accessing abortion services and the reasons why women do not use readily available effective contraceptive methods to avoid first-time or repeat abortion; and to determine how to adequately support women presenting for terminations to adopt and continue using the contraceptive of their choice. In conclusion, the repeat abortion rate remains high in Vietnam, fueled partly by inadequate contraceptive use. Strengthening postabortion contraceptive counseling and promoting long-acting reversible contraceptives—for which there is a demand among women undergoing repeat abortion—is essential for reducing repeat abortion. Risk factors for repeat abortion included region (Hanoi), higher parity, and age 35 years or older. Preference for sons seems to be a significant predictor of repeat abortion, which has important implications for Vietnam’s already skewed sex ratio at birth.
Acknowledgments Marie Stopes International provided funding for the study. Conflict of interest The authors have no conflicts of interest.
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[2] World Health Organization. Maternal mortality in Vietnam, 2000–2001: an in-depth analysis of causes and determinants. http://whqlibdoc.who.int/publications/2005/ 929061191X_eng.pdf. Published 2005. Accessed October 31, 2013. [3] General Statistics Office of Vietnam. Population change and family planning survey 1/4/ 2010 — Major findings. http://www.gso.gov.vn/default_en.aspx?tabid=515&idmid= 5&ItemID=11012. Published 2011. Accessed October 31, 2013. [4] Reproductive Health Care Centre of Ho Chi Minh City. Statistics. Ho Chi Minh City: RHCH; 2005. [5] Reproductive Health Care Centre of Ho Chi Minh City. Statistics. Ho Chi Minh City: RHCH; 2008. [6] Committee for Population, Family and Children [Vietnam], ORC Macro. Vietnam Demographic and Health Survey 2002. http://www.measuredhs.com/pubs/pdf/FR139/ FR139.pdf. Published September 2003. Accessed October 31, 2013. [7] Upadhyay UD, Brown BA, Sokoloff A, Raine TR. Contraceptive discontinuation and repeat unintended pregnancy within 1 year after an abortion. Contraception 2012;85(1):56–62. [8] Pham BN, Hall W, Hill PS, Rao C. Analysis of socio-political and health practices influencing sex ratio at birth in Viet Nam. Reprod Health Matters 2008;16(32):176–84. [9] Chatterjee P. Sex ratio imbalance worsens in Vietnam. Lancet 2009;374(9699):1410. [10] Guilmoto CZ, Hoàng X, Van TN. Recent increase in sex ratio at birth in Viet Nam. PLoS One 2009;4(2):e4624. [11] Guilmoto CZ. Son preference, sex selection, and kinship in Vietnam. Popul Dev Rev 2012;38(1):31–54. [12] Jones RK. Repeat Abortion in the United States. New York, NY: Alan Guttmacher Institute; 2006. [13] Heikinheimo O, Gissler M, Suhonen S. Age, parity, history of abortion and contraceptive choices affect the risk of repeat abortion. Contraception 2008;78(2):149–54. [14] St John H, Critchley H, Glasier A. Can we identify women at risk of more than one termination of pregnancy? Contraception 2005;71(1):31–4. [15] Nguyen TM, Chongsuvivatwong V, Geater A, Prateepchaikul L. Characteristics of repeat aborters in Vietnam. Southeast Asian J Trop Med Public Health 2000;31(1):167–72. [16] Ngo TD, Free C, Le HT, Edwards P, Pham KH, Nguyen YB, et al. Knowledge and provision practices regarding medical abortion among public providers in Hanoi, Khanh Hoa, and Ho Chi Minh City, Vietnam. Int J Gynecol Obstet 2014;124(3):216–21. [17] Thapa S, Neupane S. Risk factors for repeat abortion in Nepal. Int J Gynecol Obstet 2013;120(1):32–6. [18] Nguyen PH, Nguyen SV, Nguyen MQ, Nguyen NT, Keithly SC, Mai LT, et al. The association and a potential pathway between gender-based violence and induced abortion in Thai Nguyen province, Vietnam. Glob Health Action 2012;5:1–11. [19] Pazol K, Gamble SB, Parker WY, Cook DA, Zane SB, Hamdan S, et al. Abortion surveillance - United States, 2006. MMWR Surveill Summ 2009;58(8):1–35. [20] Cheng Y, Gno X, Li Y, Li S, Qu A, Kang B. Repeat induced abortions and contraceptive practices among unmarried young women seeking an abortion in China. Int J Gynecol Obstet 2004;87(2):199–202. [21] Makenzius M, Tydén T, Darj E, Larsson M. Repeat induced abortion - a matter of individual behaviour or societal factors? A cross-sectional study among Swedish women. Eur J Contracept Reprod Health Care 2011;16(5):369–77. [22] Prager SW, Steinauer JE, Foster DG, Darney PD, Drey EA. Risk factors for repeat elective abortion. Am J Obstet Gynecol 2007;197(6):575.e1–6. [23] Pham BN, Adair T, Hill PS, Rao C. The impact of the stopping rule on sex ratio of last births in Vietnam. J Biosoc Sci 2012;44(2):181–96. [24] Makenzius M, Tydén T, Darj E, Larsson M. Risk factors among men who have repeated experience of being the partner of a woman who requests an induced abortion. Scand J Public Health 2012;40(2):211–6.
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International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Risk factors for repeat abortion and implications for addressing unintended pregnancy in Vietnam Thoai D. Ngo a,b,⁎, Sarah Keogh b, Thang H. Nguyen c, Hoan T. Le d, Kiet H.T. Pham e, Yen B.T. Nguyen e a
Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK Research, Monitoring and Evaluation Team, Health System Department, Marie Stopes International, London, UK Research and Metrics Team, Marie Stopes International Vietnam, Hanoi, Vietnam d Department of Environmental Health, Hanoi Medical University, Hanoi, Vietnam e Department of Health Economics, Hanoi Medical University, Hanoi, Vietnam b c
a r t i c l e
i n f o
Article history: Received 19 July 2013 Received in revised form 1 November 2013 Accepted 25 February 2014 Keywords: Post-abortion family planning Repeat abortion Reproductive health Sex imbalance Unmet need Vietnam
a b s t r a c t Objective: To determine predictors of repeat abortion in 3 provinces in Vietnam. Methods: In a cross-sectional study between August and December 2011, women who underwent abortion were interviewed after the procedure in 62 public health facilities in Hanoi, Khanh Hoa, and Ho Chi Minh City (HCMC). Information on sociodemographic factors, contraceptive and reproductive history and intentions, and opinions and experience of abortion services was collected. The primary outcome was repeat (≥ 2) abortions. Results: Overall, 1224 women were interviewed: 534 from Hanoi, 163 from Khanh Hoa, and 527 from HCMC. The mean age and parity of the respondents were 29 years and 1.8, respectively, and 79.6% were married. Approximately half of the respondents were not using contraception before pregnancy. The prevalence of repeat abortion was 31.7%. In multivariate models, significant predictors of repeat abortion included living in Hanoi, higher parity, age 35 years or older, and having 2 or more daughters (versus 1) or no sons (versus 1) after controlling for parity (all P b 0.05). Conclusion: Repeat abortion remains high in Vietnam, fueled partly by inadequate contraceptive use. Son preference seems to be an important predictor of repeat abortion. Strengthening post-abortion contraceptive counseling and promoting long-acting contraceptive methods are essential to reduce repeat abortion. © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Vietnam has one of the highest abortion rates in the world, estimated at 26 abortions per 1000 women in 2007 [1]. Despite Vietnam’s liberal abortion law, unsafe abortion contributed to an estimated 11.5% of maternal deaths in 2000–2001 [2]. Vietnam’s abortion rate equates to 2.5 abortions per woman per lifetime, indicating a high level of repeat abortion. This is despite a high prevalence of contraceptive use of 78% among married women [3]. Abortion among young Vietnamese women is also increasing: in Ho Chi Minh City (HCMC), the number of abortions among females aged 10–24 years increased from 781 in 2005 to 2235 in 2007 [4,5]. Vietnam’s contraceptive provision is skewed toward the intrauterine device (IUD), which, particularly among young women, is not always the preferred contraceptive method. High rates of IUD discontinuation for method-related reasons have been documented in Vietnam, which
⁎ Corresponding author at: London School of Hygiene & Tropical Medicine and Research, Monitoring and Evaluation Team, Health System Department, Marie Stopes International, 1 Conway Street, London W1T 6LP, UK. Tel.: +44 78 8741 4504; fax: +44 20 7034 2372. E-mail address: [email protected] (T.D. Ngo).
might potentially contribute to the country’s high abortion rate [6]. Whereas 1 abortion is indicative of unintended pregnancy, repeat abortion might signify a need for improvement in family planning programs to support women presenting for terminations in adopting—and continuing on—a contraceptive method of their choice [7]. Vietnam’s sex ratio at birth increased from 106 male births per 100 female births in 2000 to 112 male births in 2008 [8–10]. Prenatal sex diagnosis and sex selection practices are prohibited in Vietnam [8]; however, it has been suggested that affordable sex determination technology has allowed Vietnamese couples to pursue their desire for 1 or more sons, thereby fuelling the high rate of abortion [8,11]. Studies in high-income countries have identified common risk factors for repeat abortion such as older age, high parity, and lower socioeconomic status [12–14]. Despite the high rate of repeat abortion in Vietnam, only 1 qualitative study has examined the characteristics of women undergoing repeat abortion in the country, and it found no sociodemographic factors associated with repeat abortion [15]. Identification of risk factors for repeat abortion might help family planning programs to design health interventions that improve contraceptive adoption and continuation subsequent to a woman’s first abortion. To address this research gap in Vietnam, the aim of the present study was to explore risk factors associated with repeat abortion among
http://dx.doi.org/10.1016/j.ijgo.2013.11.014 0020-7292/© 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
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women presenting for termination services at public health facilities in Hanoi, Khanh Hoa, and HCMC, Vietnam.
associated with repeat abortion at the bivariate or multivariate level were considered to be predictors and were included in the final model. 3. Results
2. Materials and methods The present cross-sectional exit interview survey was conducted among women receiving termination services at selected public health facilities in Hanoi municipality, HCMC municipality, and Khanh Hoa Province between August 1 and December 31, 2011. Ethical approval for the study was provided from the institutional review boards at the London School of Hygiene and Tropical Medicine and Hanoi School of Public Health, and all participants provided written informed consent before the interview. A multistage sampling strategy was implemented to select the areas, health facilities, and women. The 3 areas were selected to represent geographic and cultural differences within the country (north, south, and central, respectively). The following public health facility levels were included: central specialist and general hospitals; provincial specialist and general hospitals or reproductive health centers (RHCs); and district hospitals or RHCs. A master list of all health facilities in the 3 regions was obtained from the municipal and provincial departments of health. All specialist hospitals and RHCs specializing only in sexual and reproductive health service provision were selected, owing to the limited numbers of these facilities at each health administrative level. A random sampling strategy was used to select 50% of all nonspecialized facilities (general hospitals and commune health stations). In total, 62 health facilities were included. This sampling method was previously described [16]. All women presenting for termination services at these facilities and living in the province or municipality in which the health facility was located were eligible for inclusion. Subsequent to the procedure and counseling session, women were invited to participate in a structured face-to-face exit interview. The interview questionnaire was developed in English, translated into Vietnamese, revised after a pilot study, and back-translated into English. The questionnaire collected information on sociodemographic characteristics, abortion knowledge and attitudes, reproductive and contraceptive history, abortion experience, contraceptive and childbearing intentions, and knowledge and perceptions of abortion services. Statistical analyses were performed via Stata version 11.1 (StataCorp, College Station, TX, USA). Owing to the multistage sampling strategy of the study design, with respondents selected within facilities, all statistical analyses took clustering into account via the Stata survey (svy) commands. Because the proportion of sampled facilities differed according to the facility type, respondents attending general health facilities had half the probability of selection as those attending specialized facilities, and were thus given twice the weight of women attending specialized facilities in the analyses. Although the sample was not nationally representative, the study design ensured that it was representative of Hanoi, Khanh Hoa, and HCMC. Descriptive analyses were carried out to show the distribution of sociodemographic, reproductive, and abortion-related characteristics both overall and for first-time versus repeat abortion groups. The distribution of contraceptive methods (past use, intended use, and reasons for non-use) and barriers to accessing abortion were examined in a similar manner. A P value of less than 0.05 was considered to be statistically significant. Bivariate and multivariate logistic regression models were used to determine predictors of repeat abortion. Variables considered as potential predictors included sociodemographic characteristics, reproductive and contraceptive history, reproductive and contraceptive intentions, abortion characteristics (gestational age and type of abortion), and factors related to abortion service access (cost, distance, and perceived accessibility). Whether number of sons and/or daughters was predictive of repeat abortion was also tested. Only factors that were significantly
During the study period, 1224 women completed the survey: 534 from Hanoi, 163 from Khanh Hoa, and 527 from HCMC. This represented a 99.7% response rate. The mean age of respondents was 28.8 years. More than 50% were aged 20–30 years, approximately 43% were aged over 30 years, and 6.2% were younger than 20 years. Almost 80% of respondents were married, and 58.1% had at least high school education (8.8% had primary level or no education). Approximately one-third of respondents had no children, and 7.4% had more than 2 children. Half of the respondents were using contraception before the recent pregnancy, and most (86.5%) expressed their intention to use contraception after the abortion. Almost 43% of respondents wanted to stop childbearing, and 18.1% intended to have a child within 2 years (Table 1). The prevalence of repeat abortion, defined as 2 or more abortions, was 31.7%. Women undergoing repeat abortion were similar to those undergoing first-time abortion in terms of educational attainment, distance traveled to clinic, and gestational age. Among all women, gestational age at the time of termination ranged from 0 to 29 weeks (52.3% at 5–6 weeks, and 6.4% at ≥9 weeks). Only 32 respondents (or 2.6% of the total sample) were in their second trimester. Compared with those undergoing first-time abortion, those undergoing repeat abortion were more likely to be married (90.0% vs 75.0%; P ≤ 0.001) and from Hanoi (50.5% vs 34.7%; P = 0.016). They were also older (P ≤ 0.001) with higher parity (P ≤ 0.001), and were more likely to want to stop childbearing than women undergoing first-time abortion (63.6% vs 33.7%; P ≤ 0.001). They were also more likely to have a surgical (rather than medical) abortion compared with women in the firsttime abortion group (85.5% vs 72.7%; P = 0.030). Among the respondents, condoms were the most popular contraceptive method, followed by the pill and emergency contraception (Fig. 1); there were no significant differences between first-time and repeat abortion. When asked about the reasons for non-use of contraceptives, women in the first-time abortion group were more likely than those in the repeat abortion group to cite lack of contraceptive knowledge (23.4% vs 12.4%; P = 0.039), but less likely to cite partner disapproval (21.2% vs 28.3%; P = 0.020). With regard to contraceptive intentions subsequent to the abortion, the pill (37.8%) and condoms (35.5%) remained the most popular methods, followed by the IUD (27.4%). Intention to use condoms was significantly lower among women undergoing repeat abortion than among those undergoing first-time abortion (27.1% vs 39.9%; P ≤ 0.001), in contrast to past condom use (Fig. 1). There was a significant association between repeat abortion and intention to adopt user-independent methods (sterilization, IUD, and injectables) versus user-dependent methods (condoms, pill, emergency contraception, periodic abstinence, and withdrawal) (P = 0.034). Overall, 34.4% of women undergoing repeat abortion expressed the intention to adopt only user-independent methods, compared with 26.3% of women undergoing first-time abortion. By contrast, 68.7% of women in the first-time abortion group intended to use only user-dependent methods, compared with 56.6% of women in the repeat abortion group. Most women undergoing both first-time (75.9%) and repeat (81.6%) abortion thought that abortion services were accessible in their area of residence. Each of the main barriers to accessing abortion services (lack of knowledge, cost, distance, and reluctance to use a public provider) was cited by 10% or less of respondents in both groups (Fig. 2). Stigma seemed to be a far greater barrier in the first-time abortion group than in the repeat abortion group (17.5% vs 7.0%; P = 0.012). The proportion of respondents citing each barrier to accessing abortion was between 2 and 17 times higher in Khanh Hoa than in the other regions. For instance, 30.2% of respondents in Khanh Hoa said that they
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Table 1 Characteristics of women stratified by repeat and first-time abortion. Characteristics Socio-demographic Age group, y 14–19 20–24 25–29 30–34 ≥35 Region Hanoi Khanh Hoa HCMC Marital status Single Married Living with partner Educational attainment None/primary Secondary High school/technical College/uni/postgrad Number of children 0 1 2 3–8 Number of sons 0 1 2–4 Number of daughters 0 1 2–4 Abortion-related Was using FP before this pregnancy Type of procedure today Surgical abortion Medical abortion Distance traveled from home, km b5 5–9 10–19 ≥20 Gestational age at abortion, wk ≤4 5–6 7–9 ≥9 Reproductive intentions Childbearing desires No more children Child within 2 y Child after 2 y Doesn’t know Wants to use FP after abortion? Yes No Doesn’t know
Overall sample (n = 1224)
First-time abortion group (n = 818)
Repeat abortion group (n = 406)
P valuea
6.2 27.3 23.7 19.1 23.6
8.5 33.7 24.7 17.1 16.1
1.3 13.7 21.6 23.5 39.9
≤0.001
39.8 10.4 49.8
34.7 11.9 53.3
50.5 7.2 42.3
0.016
17.1 79.6 3.3
21.6 75.0 3.4
7.2 90.0 2.8
≤0.001
8.8 33.1 36.1 22.0
8.1 32.3 36.6 23.0
10.4 34.8 35.1 19.7
0.457
30.7 24.9 37.1 7.4
39.0 27.6 27.6 5.8
12.7 19.0 57.6 10.7
≤0.001
49.4 37.6 13.0
58.4 31.7 9.9
31.1 49.4 19.5
≤0.001
57.8 32.2 10.0
64.3 29.1 6.6
44.8 38.6 16.7
≤0.001
50.3
48.0
55.2
0.075
76.8 23.2
72.7 27.3
85.5 14.5
0.030
30.7 30.8 24.9 13.6
29.6 30.2 25.6 14.6
33.0 32.3 23.2 11.5
0.624
17.1 52.3 24.2 6.4
16.2 52.1 24.5 7.2
18.9 53.2 23.3 4.6
0.210
42.9 18.1 28.3 10.7
33.7 19.9 34.1 12.3
63.6 13.9 15.3 7.2
≤0.001
86.5 11.4 2.2
85.4 12.7 1.9
88.9 8.4 2.7
0.341
Abbreviation: FP, family planning. Values are given as a percentage unless stated otherwise.
a
would prefer a private provider, compared with 6.1% in Hanoi and 2.4% in HCMC (P ≤ 0.001). Stigma was cited by a significantly higher proportion of respondents in both Khanh Hoa (43.6%) and HCMC (12.2%) than in Hanoi (5.6%; P ≤ 0.001). In bivariate analyses, the odds of repeat abortion were significantly lower in Khanh Hoa (odds ratio [OR] 0.41; 95% confidence interval [CI], 0.27–0.64; P = 0.004) and HCMC (OR 0.54; 95% CI, 0.33–0.90; P = 0.027) than in Hanoi, and increased significantly with age (P ≤ 0.001) and parity (P = 0.002). Being single (P ≤ 0.001), having no daughters (versus 1) (P = 0.008), and having no sons (versus 1) (P ≤ 0.001) were associated with lower odds of repeat abortion. By contrast,
having several daughters (versus 1) (OR 1.78; 95% CI, 1.13–2.81; P = 0.023) significantly increased the odds of repeat abortion. To examine the overall effect of the sex distribution of children, parity by sex composition (hereafter “parity–sex”) was examined. Using the reference category of “1 son and 1 daughter,” the odds of repeat abortion were still significantly lower for women who had 0 sons and 0 (P ≤ 0.001) or 1 daughter (P = 0.006), and women who had 0 daughters and 1 son (P = 0.020). However, unlike in the previous regression, which used number of daughters instead of the parity–sex variable, the odds of repeat abortion for women with 2–4 daughters (P = 0.747) were not significantly higher than the reference category. This was
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Fig. 1. Proportion of women who used contraceptives before the pregnancy and who intend to use in future, for first and repeat abortion clients.
due either to smaller cell sizes in the narrowly defined parity–sex categories (leading to decreased significance) or to the particular choice of reference category, which obscures the broader effects of the number of daughters on repeat abortion when “number of sons” categories are combined. The odds of repeat abortion were significantly lower among women who wanted more children (P ≤ 0.001) or were unsure than among women who wanted to stop childbearing (P = 0.002). In a multivariate analysis controlling for sociodemographic characteristics (region, age, marital status, and number of children), repeat abortion was no longer associated with childbearing desire or marital status. The direction of association with age and parity remained the same but decreased in strength. Having 0 sons (versus 1) significantly decreased the odds of repeat abortion (OR, 0.41; P = 0.009), whereas having several daughters (versus 1) increased the odds nearly 3-fold (OR, 2.94; P ≤ 0.001). Having 0 daughters (versus 1) was no longer associated with lower odds of repeat abortion, indicating that this association was explained by parity. This was confirmed in a regression using the parity–sex variable instead of parity: compared with women with 1 son and 1 daughter (the reference category), the odds of repeat abortion were significantly lower for women who had 0 sons, and 0 or 1 daughter (P ≤ 0.001 and P = 0.015, respectively). Unlike in the previous regression, which used number of daughters instead of the parity–sex variable, having 2–4 daughters was not associated with a significantly higher odds of repeat abortion compared with the reference category. The regression using number of daughters instead of the parity–sex
variable showed that when the analysis controlled for the number of sons, having 2–4 daughters compared with 1 daughter significantly increased the odds of repeat abortion. The odds of repeat abortion remained lower in Khanh Hoa (OR, 0.45; P = 0.039) and HCMC (OR, 0.56; P = 0.042) than in Hanoi. There were no significant differences between the first-time and repeat abortion groups in reported cost and distance to clinic, or in the proportion of women who said that abortion services were accessible; inclusion of these variables in the multivariate model did not alter the association between region and repeat abortion (Table 2). 4. Discussion In the present survey of Hanoi, HCMC, and Khanh Hoa Province in Vietnam, approximately one-third of abortion-seeking women had had a repeat abortion (31.7%). This figure is higher than that found in a study in Thai Nguyen Province, which documented a prevalence of 11.5% [16], but is similar to or lower than estimates in both lowresource (32.3% in Nepal [17]) and high-resource (30%–38% in northern Europe [18] and 48% in the United States [17]) settings. The prevalence of repeat abortion among unmarried women was much lower in the present survey than in China (7% vs 33%), a country that is socioculturally similar to Vietnam [13]. In the present study, risk factors for repeat abortion included region (Hanoi), higher parity, age 35 years or older, and 2 or more daughters (versus 1) or 0 sons (versus 1). Studies in Nepal, Europe, and the
Fig. 2. Proportion of women citing the following barriers to accessing abortion, for first-time and repeat abortion clients.
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Table 2 Predictors of repeat abortion. Variable Socio-demographic characteristics Region Hanoi Khanh Hoa HCMC Age group, y 14–19 20–24 25–29 30–34 ≥35 Marital status Single Married Living with partner Number of children 0 1 2 3–8 Other characteristics Number of sons 0 1 2–4 Number of daughters 0 1 2–4 Parity by sex compositionb 0 sons, 0 daughters 0 sons, 1 daughter 0 sons, 2–4 daughters 1 son, 0 daughters 1 son, 1 daughter 1 son, 2–4 daughters 2–4 sons, 0 daughters 2–4 sons, 1 daughter 2–4 sons, 2–4 daughters Childbearing desires No more Within 2 y After 2 y Doesn’t know
Crude OR (95% CI)
1.00 0.41 (0.27–0.64) 0.54 (0.33–0.90) 0.37 (0.18–0.86) 1.00 2.15 (1.41–3.29) 3.38 (2.56–4.46) 6.12 (4.26–8.78)
P value
0.004 0.027 0.028 0.006 ≤0.001 ≤0.001
0.27 (0.17–0.45) 1.00 0.69 (0.21–2.21)
≤0.001
0.47 (0.30–0.75) 1.00 3.03 (1.80–5.11) 2.66 (1.78–3.98)
0.008
0.35 (0.30–0.40) 1.00 1.22 (0.98–1.53)
≤0.001
0.52 (0.35–0.77) 1.00 1.78 (1.13–2.81)
0.008
0.16 (0.12–0.20) 0.21 (0.08–0.50) 1.14 (0.57–2.25) 0.45 (0.24–0.82) 1.00 1.29 (0.57–2.92) 0.94 (0.58–1.52) 0.76 (0.23–2.48) 1.05 (0.73–1.50)
≤0.001 0.006 0.649 0.020
1.00 0.37 (0.27–0.50) 0.24 (0.18–0.32) 0.31 (0.19–0.50)
0.445
0.003 0.002
0.068
0.023
Adjusted OR (95% CI)a
1.00 0.45 (0.21–0.94) 0.56 (0.33–0.97)
P value for adjusted OR
0.039 0.042
0.46 (0.17–1.24) 1.00 1.50 (0.79–2.83) 1.72 (0.99–3.01) 3.05 (1.65–5.65)
0.101
1.24 (0.61–2.50) 1.00 3.08 (0.82–11.58)
0.469
0.62 (0.27–1.43) 1.00 2.18 (1.33–3.58) 1.75 (0.88–3.47)
0.201
0.41 (0.23–0.71) 1.00 1.32 (0.80–2.18)
0.009
0.77 (0.35–1.71) 1.00 2.94 (1.93–4.47)
0.444
0.465 0.741 0.581 0.747
0.29 (0.19–0.45) 0.29 (0.12–0.70) 1.17 (0.54–2.52) 0.63 (0.33–1.20) 1.00 1.20 (0.52–2.76) 0.95 (0.58–1.53) 0.78 (0.18–3.44) 1.00 (0.45–2.26)
≤0.001 ≤0.001 0.002
1.00 1.16 (0.63–2.15) 0.94 (0.53–1.67) 1.03 (0.53–2.02)
0.163 0.054 0.006
0.080
0.010 0.092
0.219
≤0.001 ≤0.001 0.015 0.621 0.126 0.608 0.778 0.690 0.991
0.555 0.798 0.900
Abbreviations: CI, confidence interval; HCMC, Ho Chi Minh City; OR, odds ratio. a Adjusted for socio-demographic characteristics. b Not adjusted for parity owing to endogeneity of the 2 variables.
United States have also reported age and parity as important predictors of repeat abortion [19–21]. Whereas surveys in Europe and the United States have highlighted low education or income as predictors of repeat abortion, socioeconomic status did not emerge as a predictor in the present analysis. Previous studies have proposed correlations in Vietnam among son preference, the high abortion rate, and the sex ratio imbalance at birth [10,22]. The present findings suggest that preference for a son is associated with a higher likelihood of having a repeat abortion. Women with 0 sons were significantly less likely to have a repeat abortion than those with 1 son. This is consistent with a previous study showing that Vietnamese couples stop childbearing after they have had 1 son [9]. The present findings and those of others suggest that Vietnam’s “1–2” child policy and son preference both have a potential effect on the country’s repeat abortion rate. Although the Vietnamese cultural preference for sons would be difficult to address through health interventions, the “1–2” child policy might be revisited to reflect the country’s commitment to promotion of healthy family planning. The present findings showed that Vietnamese women presenting for abortion relied heavily on user-dependent contraceptives. In contrast to the general female population of reproductive age in Vietnam, among
whom the IUD is used by 51.2% of married women [23], women undergoing repeat abortion in the present survey (90% of whom were married) used less effective methods such as contraceptive pills and condoms. The repeat abortion group also had a higher percentage of past use of condoms compared with the first-time abortion group, suggesting that these women prefer short-term methods and adopt reactive rather than proactive contraceptive behavior. Women who had a repeat abortion were more likely to consider user-independent methods for the future, suggesting that repeat abortion might serve as an incentive to start using a more effective method. This highlights the need for Vietnam’s family planning program to expand its range of long-acting reversible contraceptives by making implants available and accessible in conjunction with IUDs. In the repeat abortion group, the main barrier to contraceptive use was partner disapproval. To adequately prevent repeat abortion caused by unintended pregnancy, targeted interventions are required through Vietnam’s family planning program to actively engage men in reproductive health education programs. The present study involved a large cross-sectional survey of abortionseeking women across 3 regions in Vietnam. It does, however, have some limitations. Although the sampling design enabled the data to be
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more representative of the general population of abortion-seeking women in Vietnam, the regions selected include more established municipalities and provinces that might not be representative of smaller provinces in rural areas. Previous studies have suggested that alcohol or drug use and gender-based violence might be predictors of repeat abortion [16,21,22,24]; however, information on these factors was not collected in the present survey. Stigma emerged as an important barrier to accessing abortion services in the present study but, owing to the nature of the quantitative survey, it was not possible to investigate the nature of this stigma in any depth. There is a need for improvement in Vietnam’s national family planning program to address the disconnection between the high repeat abortion rate and the high prevalence of contraceptive use. Further research and program efforts are required to understand the barriers to accessing abortion services and the reasons why women do not use readily available effective contraceptive methods to avoid first-time or repeat abortion; and to determine how to adequately support women presenting for terminations to adopt and continue using the contraceptive of their choice. In conclusion, the repeat abortion rate remains high in Vietnam, fueled partly by inadequate contraceptive use. Strengthening postabortion contraceptive counseling and promoting long-acting reversible contraceptives—for which there is a demand among women undergoing repeat abortion—is essential for reducing repeat abortion. Risk factors for repeat abortion included region (Hanoi), higher parity, and age 35 years or older. Preference for sons seems to be a significant predictor of repeat abortion, which has important implications for Vietnam’s already skewed sex ratio at birth.
Acknowledgments Marie Stopes International provided funding for the study. Conflict of interest The authors have no conflicts of interest.
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