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Induced abortion among HIV-positive
women in Northern Vietnam: exploring
reproductive dilemmas
Bi Kim Chi
a
, Vibeke Rasch
c
, Nguyn Thi Thy Hnh
b
& Tine
Gammeltoft
c
a
Institute of Population and Development Studies, Hanoi, Vietnam
b
Faculty of Public Health, Hanoi Medical University, Vietnam
c
Faculty of Health Sciences, Institute of International Health,
Department of International Health, Immunology and Microbiology,
University of Copenhagen, Denmark
d
Department of Anthropology, University of Copenhagen, Denmark
Version of record first published: 08 Jul 2009.
To cite this article: Bi Kim Chi , Vibeke Rasch , Nguyn Thi Thy Hnh & Tine Gammeltoft (2010):
Induced abortion among HIV-positive women in Northern Vietnam: exploring reproductive dilemmas,
Culture, Health & Sexuality: An International Journal for Research, Intervention and Care, 12:S1,
S41-S54
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Induced abortion among HIV-positive women in Northern Vietnam:
exploring reproductive dilemmas
Bu`i Kim Chi
a
*, Nguye

n Thi

Thuy Ha
_
nh
b
, Vibeke Rasch
c
and Tine Gammeltoft
d
a
Institute of Population and Development Studies, Hanoi, Vietnam;
b
Faculty of Public Health, Hanoi
Medical University, Vietnam;
c
Faculty of Health Sciences, Institute of International Health,
Department of International Health, Immunology and Microbiology, University of Copenhagen,
Denmark;
d
Department of Anthropology, University of Copenhagen, Denmark
(Received 7 September 2008; nal version received 20 May 2009)
Across the world, childbearing among HIV-positive women is a socially controversial
issue. This paper derives from a larger research project that investigated reproductive
decisions among HIV-positive women in Quang Ninh, a northern province of Vietnam.
The paper focuses on 13 women who had an abortion after being diagnosed as
HIV-positive, exploring their reections, concerns and dilemmas. The results show that
the HIV-positive pregnant women sought to balance their desires for a child with their
worries of being unable to fulll their responsibilities as mothers. Even while strongly
desiring to become mothers, women in this study opted to terminate their pregnancies
out of fear that they could not care adequately for the child they expected. These
results indicate that when providing reproductive health counselling and support
for HIV-positive women and their families, it is essential to take into account the
socio-cultural factors that shape womens reproductive options.
Keywords: HIV; pregnancy; abortion; PMTCT; Vietnam
Introduction
Globally, increasing numbers of women of childbearing age are infected with HIV.
By December 2007, the Joint United Nations Programme on HIV/AIDS (UNAIDS)
estimated that of 33.2 million persons living with HIV worldwide, about 15.4 million
were women aged 15 years and over (UNAIDS 2008). Many HIV-positive women are
therefore in a situation where they must make decisions regarding whether or not to have
children and, if they have already become pregnant, whether or not to continue the
pregnancy.
Over the past few years, prevention-of-mother-to-child-HIV-transmission pro-
grammes have become increasingly available for women across the globe, covering
several areas such as counselling and testing for pregnant women and anti-retroviral
therapy for preventing mother-to-child transmission of HIV. Prevention-of-mother-to-
child-transmission is a means of reducing the risk of infant infection and it encourages
many HIV-positive women to consider childbearing (Cooper et al. 2005, 2007; Van
Hollen 2007). Recent research has shown that with the availability of prevention-of-
mother-to-child-transmission, childbearing among HIV-positive people is still a socially
contested eld. Some studies report that HIV-positive women are socially pressured to bear
ISSN 1369-1058 print/ISSN 1464-5351 online
q 2010 Taylor & Francis
DOI: 10.1080/13691050903056069
http://www.informaworld.com
*Corresponding author. Email: chibuikim@yahoo.com
Culture, Health & Sexuality
Vol. 12, No. S1, August 2010, S41S54
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children (Cooper et al. 2007; Oosterhoff et al. 2008; Van Hollen 2007), while other studies
show that women living with HIV are pressured to terminate their pregnancies (De Bruyn
2005). Even though antiretroviral therapy is available, HIV-positive people still have
shorter lives than other people: even in high-income countries, the life expectancy
HIV-positive persons is only two thirds of that of the general population (Antiretroviral
Cohort Collaboration 2008).
This paper derives from a larger research project that investigated reproductive
decisions among HIV-positive women in Quang Ninh, Vietnam. In it we explore what
motivated pregnant HIV-positive women to terminate their pregnancies in a situation
where they also expressed strong desires to become mothers. We analyse interviews with
13 women who had an abortion after being diagnosed as HIV-positive, describing their
desires for children, their experience of abortion and examining the factors that shaped
their motivation to seek an abortion. We argue that the womens sense of maternal
responsibility was a particularly important socio-cultural factor compelling them to
terminate their pregnancy in a situation where they longed to have a child. Based on results
from this study, we discuss how a more supportive social environment for HIV-positive
women of childbearing age can be generated.
Setting: HIV and abortion in Vietnam
In Vietnam, there presently exists a concentrated HIV epidemic and the main risk factors
associated with HIV infection are the use of contaminated injecting equipment and
unprotected sex. By March 2008, the reported number of people living with HIV/AIDS in
Vietnam was 149,989 (Vietnam Administration of HIV/AIDS Control [VAAC] 2008).
Of these, women accounted for 17% (VAAC 2008), many of whom had been infected with
HIV by husbands (or regular partners) who were injecting drug users (United Nations
General Assembly Special Session [UNGASS] 2008).
According to data from the annual national HIV sentinel surveillance, the HIV
prevalence among pregnant women has increased dramatically in the past decade, from
0.02% in 1994 to 0.38% in 2007 (VAAC 2008). In 2007, 1920 HIV-positive women gave
birth in Vietnam and 3603 children under 16 years were infected with HIV from their
mothers (VAAC 2008). However, the majority of HIV-positive women are not detected by
the healthcare system and the actual number of HIV-positive women giving birth is likely
to be much higher (Oosterhoff 2008).
In Vietnam, prevention-of-mother-to-child-transmission has been offered since 1996.
Developed from a simple model to a more complex approach which includes four prongs:
(1) primary prevention of HIV/AIDS; (2) prevention of unwanted pregnancy in
HIV-positive women; (3) prevention of HIV transmission from mothers to children; and
(4) care and support for HIV-positive mothers and their children and families. In 2002, the
Boehringer Ingelheim Nevirapine donation programme marked the start of expanding
interventions aimed at prevention-of-mother-to-child-transmission (Morch et al. 2006).
At the same time from the year 2001 Vietnams new population policy was launched.
This policy places emphasis on population quality and turns the birth of sick or disabled
children into a political issue (Gammeltoft 2008).
However, coverage of prevention-of-mother-to-child-transmission services is
presently low (Morch et al. 2006). In 2006, 16.5% of pregnant women reported to have
had an HIV test, 21% of ANC services facilities provided the basic minimum package of
prevention-of-mother-to-child-transmission services and 492 HIV-positive pregnant
women received three-combination ARV prophylaxis for prevention-of-mother-to-child
S42 B.K. Chi et al.
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transmission (UNGASS 2008). Recent research conducted in a well-resourced healthcare
setting in Hanoi showed that only 20% of 52 HIV-positive women involved in the
study had received comprehensive prevention-of-mother-to-child-transmission services
(Thu Anh Nguyen et al. 2008).
In Vietnam, induced abortion is legal and is performed until 22 weeks of gestation.
The ofcially reported abortion rate in Vietnam has declined from 83 per 1000 women
aged 1544 in 1996 to 26 in 2003. Ofcial rates of abortion are, however, likely to be
underestimated as many abortions are not registered (Sedgh et al. 2007). Induced abortion
is a morally sensitive issue in Vietnam and existing research shows that for many women
and their partners, abortion decisions are difcult (Gammeltoft 2002). The high rates of
abortion in Vietnam must be seen in the context of national population and family
planning policies which encourage people to have no more than two children and in
the context of peoples own desires to control their fertility (Gammeltoft 2002; Johansson
et al. 1996). Although childbearing is highly valued in Vietnam, current normative
expectations among ethnic majority Vietnamese centre on a small family. Fertility rates
have declined rapidly over the past decades, dropping further from 2.33 children per
woman in 1999 to 2.07 in 2007 (General Statistics Ofce 2008).
Methods
Study site
Quang Ninh province is located in the North of Viet Nam with a population of more than
1.1 million and the highest HIV prevalence in the country (UNGASS 2008). Ha Long city
and Cam Pha town, which were selected as study sites, have the highest HIV prevalence in
Quang Ninh. The prevalence of HIV-positive pregnant women increased from 0.25% in
2001 to 1% in 2005.By the end of 2004, the governments prevention-of-mother-to-child-
transmission programme had been implemented at all commune health centres in Ha Long
and Cam Pha. In Quang Ninh in 2006, 88% of women diagnosed HIV-positive during
labour received a single drug prophylactic ARV regimen and nearly all exposed infants
were administered prophylactic ARVs. Most infants received multiple ARV prophylaxis
according to the national guidelines, irrespective of whether they were born at provincial
or district level facilities (Morch et al. 2006).
Participants
Twenty HIV-positive women participated in the qualitative component of the research.
These women had all been in a situation where they were pregnant and HIV-positive;
10 women received the HIV diagnosis during antenatal care, while 10 knew that they were
HIV-infected prior to getting pregnant. Of these 20 women, 19 claimed that they had been
infected with HIV by their husbands who were drug users or had had unsafe sex. Only one
had a husband who was HIV-negative; she could not identify her mode of transmission.
Among the 20 women, 13 opted for an abortion and seven women continued their
pregnancies to full term. The demographic characteristics of these 13 women are shown in
Table 1.
Data collection and analysis
The study was conducted from April to October 2007. This is a community-based study
using both quantitative and qualitative approaches. In the quantitative component,
Culture, Health & Sexuality S43
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interviews were conducted with 351 HIV-positive women of reproductive age. Of these,
54 women reported having been pregnant after they were diagnosed with HIV.
These women were invited to take part in the qualitative component of the research and 20
accepted the invitation. The interviews were conducted by the rst author in a setting
chosen by the women, most often at the hotel where the researcher was staying. Only two
Table 1. Characteristics of 13 women who opted for an abortion.
Characteristics N
Age
$ 30 8
. 30 5
Marital status
Married 7
Widowed, no sexual partner 2
Widowed, cohabiting with new partner 4
Education
Incompleted primary school 1
Completed primary school 3
Completed lower secondary school 6
Completed upper secondary school 2
Higher 1
Self-assessed economic status
Poor 8
Average 4
Well off 1
Occupation
Unemployed 6
Petty trader 3
Tailor 2
Worker/government staff 2
Time of being diagnosed as HIV-positive
Before 2002 2
20022005 10
2007 1
Number of abortions after HIV diagnosis
1 9
2 3
3 1
Time of having abortions after HIV diagnosis
2003 2
2004 1
2005 5
2006 1
2007 4
Gestation of last pregnancy after HIV diagnosis
First trimester 9
Second trimester 4
Number of children of the time of the study
None 6
One existing child 7
Having HIV-positive children (including children who died) 9
Receiving ARV treatment 10
S44 B.K. Chi et al.
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women preferred to talk with the researcher in their home. The interview topics included:
attitudes towards childbearing, womens experiences of childbearing and the decision
regarding whether to give birth or terminate the pregnancy. These issues were very
sensitive and emotionally troubling for the women to talk about. The researcher, Bui, did
her best to provide encouragement and support, allowing the women to talk relatively
freely and avoiding pressuring them to talk about given topics. Each interview lasted
approximately three hours. All interviews were taped-recorded with the consent of the
women and later transcribed verbatim. Information obtained from each in-depth interview
was summarised and preliminarily analyzed during the eldwork. All transcriptions were
coded and organised according to research themes.
Ethical considerations
The condentiality and anonymity of the women were ensured. Informed consent was
obtained. The study was ethically approved by the Scientic Committee of the Vietnamese
Commission for Population, Family and Children and by the Danish National Committee
on Biomedical Research Ethics.
Results
Child desires
When we met her, Nga was 30 years old. She got married in 2001. At that time she and
her husband were very poor. Her husband worked as a miner while she was a hair stylist.
In 2002, Nga became pregnant but she had a miscarriage some weeks later. She became
pregnant again in the beginning of 2003. She had an ultrasound scan and was very happy
knowing she was pregnant with twins. She told us about her happiness when being pregnant:
At rst I had a quick test and knew I got pregnant. I and my husband were very happy. During
the rst days he bought a lot of nourishing foods for me. We called our parents and told them
I was pregnant. Everybody in our family was happy and asked me to be careful with the
foetuses. My husband was happiest. He treated me very well. He helped me with the smallest
things, for instance he helped me wash clothes or encouraged me to eat more. It was our
happiest time.
Nga described her hope and expectations for her children:
I wished to be healthy and hoped that I would not have a miscarriage. Like other mothers,
I hoped my children would be healthy and I had a lot of nourishing foods and tonics. I also
talked to neighbors who experienced giving birth. We dared not have sex due to the risk of
miscarriage. I hoped the children would bring happiness for us and be a tie between me and
my husband. And people do not consider me die

c (an infertile woman). The children would

make us live longer.
Nga imagined her future family life after her delivery:
I so much wanted to have a child. Having children would make my husband come back home
early. He would look after them while I prepared the dinner. After dinner we would go out
together. I made a sketch of dreams but real life was not like that.
When she was three months pregnant, Nga had a slight discharge of blood and went to the
hospital. They tested her and she was diagnosed as HIV-positive. When the doctor informed
her about her status, she fainted. The diagnosis became a turning point in her life. The couple
was in shock and her husband admitted his fault that he maybe was infected with HIV due
to sharing needles with his friends. One month later, Nga and her husband decided to
terminate the pregnancy. Nga was in great torment after the abortion. She stated:
Culture, Health & Sexuality S45
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I feel my husband does not love me anymore because as a woman, I cannot have a child and
we have no ties. Seeing pregnant women, I wish I would experience this feeling. I want to
know how to have labor pains. I have many friends who were pregnant. Each time when they
gave birth, I asked them how they felt and whether they had a pain. Sometimes I think I am in
this situation because my ancestors led immoral lives.
Nga decided to get pregnant again. She said she and her husband gambled their life on this
decision because they were not sure if the child would be HIV-positive or not. They did not
use any contraception but she could not get pregnant anymore. She felt regret for
the previous abortion because she now thought that her children could have been
HIV-negative. Nga said that if she got pregnant now, she would not have had an abortion
but seek a good counselling service.
Ngas story illustrates an HIV-positive womans erce desire to become a mother.
Like Nga, all the HIV-positive women in our study felt that HIV broke and threatened their
lives, but they still wanted to become mothers. Many women saw a child as the outcome of
the love of the couple. The existence of a child creates a warm atmosphere in the family,
they said, and the couple will have a stronger attachment to each other if they have a child:
I desire a child because it is an outcome of our lives. We are very sad because we have been
living together for some years but have no children. Our life is so sad. I wish I can have a child so
that our life can become warmer and we will love each other much more. (Huong, 36 years old)
Those of the women who had no children at the time of the study expressed even stronger
desires for motherhood than women who had a live child; these women felt that they did
not have many opportunities to become mothers as their life would be shortened due to
HIV. They felt that not only did they not experience the happiness of motherhood, but they
also failed to live up to their family-in-laws expectations by fullling the responsibility of
a daughter-in-law and bearing a child for the lineage:
I really desire a child. There are only two people in my family: me and my husband, our life is
sad. My husband is the eldest son in his family, so I very much want to have a male child to
continue the family line. (Mai, 30 years old)
Often, not only the women but also their husbands strongly desired to have a child. One
woman told us that her husband, who was also HIV-positive, pressured her to have a child.
He threatened that if she did not accept to have a child, he would nd another woman to
bear a child for him. The men often seemed to feel that their masculinity was compromised
if they did not have children:
My husband likes children very much. He always wants me to bear a child for him. When
talking with his friends, he often afrms that we are going to have three children in all. His
friends mock at him and say that you are infertile, you just brag to save face. They do not
know we are HIV-positive. (Hau, 30 years old)
Some women whose husbands had died were living with a sexual partner. Whether
HIV-positive or not, these men often wanted to have a child with the woman they were
living with. Lan, a 33-year-old woman, having a 7-year-old HIV-negative daughter, who
was living with a HIV-negative partner stated:
He desires a child. He said we could have a child. If we had a child, we would bottle-feed it.
He likes children very much. He promises if I bear a male child for him, he will buy
everything I want, even a car.
Or Hoa, a 30-year-old woman, having an HIV-positive son and living with a HIV-positive
partner said:
He says he is building a house. We will get married when the house is ready and we will have a
child. He wants a child and we will try our best to bring it up when we are still alive. Hopefully
S46 B.K. Chi et al.
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the child will not be HIV-positive. He says mother-to-child-transmission-prevention medicine
is available now and he has enough money to buy medicine to treat me and the child.
Some women who already had an HIV-positive child longed to have a second child.
Prevention-of-mother-to-child-transmission programmes that provide drugs for both
mothers and children brought hope to the women that they could have another child who
would be HIV-negative. This, they felt, would alleviate the pain they felt as a mother of an
HIV-positive child:
I want to bear another child because I already have an HIV-positive one. Now prevention-of-
mother-to-child-transmission medicine is available, so I desire a child, boy or girl, no
problem. The most important thing is that this child is not HIV-positive. (Van, 27 years old)
In spite of their strong desires to have a child, to experience the joy and happiness they
associated with motherhood and to fulll the expectations of husbands, partners or in-laws,
the 13 women at the centre of this article still opted to terminate their pregnancy. The next
section describes their abortion experiences.
Opting for abortion
Vy was 33 years old at the time of the research. She had a seven-year-old daughter who
was HIV-negative. In 2005, she was diagnosed as HIV-positive when pregnant and she
decided to terminate her pregnancy. The most important reason why she made this
decision was that she feared she could not live for very long. She also worried that her
child would be HIV infected and that its life would be hard. She imagined that the child
would be discriminated against, nobody would dare hold it, communicate with it and the
child would not be allowed to go to school. One more thing Vy feared was she would not
have good enough economic conditions to take care of the child because she was very poor
and her own parents were poor too. At that time Vy was over ve months pregnant. She
discussed the decision with her husband, but he did not agree for her to have an abortion.
Still, she went through with her decision. At the hospital, she explained that she wanted to
terminate her pregnancy because her husband was terminally ill due to HIV, she was HIV
infected too. She had an ultrasound scanning and was informed that her fetus was healthy
and it was a son. The abortion took several days and was very painful. During labour, she
whispered to her foetus I did not want to leave you but both of us would be miserable if
I gave birth. Your father could not live longer and we would die, too. When she came
home, her husband was seriously ill. Before dying, he still did not accept that she had had
the abortion.
Later, Vy regretted her abortion decision:
I felt I went wrong but I did not know what to do . . . . At that time, I wanted to end my
pregnancy as soon as possible because I was very poor and I feared my child would suffer
misery. Now my economic status is much better, I can bring my children up so I feel very
sorry. I wondered if the doctors buried it or threw it away. One night I dreamt that my husband
gave the child to me and said Here is our son. Hold him for a while and I will take him away.
People say that if a big foetus is aborted, the mother would often dream of it but I saw him
only once in a dream.
Vys story illustrates the impossibility of mothering felt by a potential mother, even when
the ultrasound scanning showed that the foetus was the son that she and her husband had
hoped for. Vy did not let her child be born because she feared she could not give it health, a
normal life and bring it up. Other women in our sample had earlier abortions than Vy, but
many felt like her that the abortion decision was excruciating and the abortion a painful
experience. These feelings often seemed to be grounded in womens perceptions of the
Culture, Health & Sexuality S47
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foetus as a potential child; many women felt that having an abortion meant taking the life
of a potential human being:
Anyhow, it was a human being. I have heard about women who had abortions at three or four
months gestation . . . . The soul of the foetus returned to haunt them. (Hoa, 30 years old)
Some women felt very sorry after terminating their pregnancy. This regret often arose
when they realised that prevention-of-mother-to-child-transmission programmes now
exist that can help prevent mother-to-child transmission of HIV. At the time of abortion,
they did not have enough knowledge on this issue. They believed that the child could not
avoid being HIV-infected. Some of the women said that they would have continued the
pregnancy if they had known about the availability of prevention-of-mother-to-child-
transmission. Vy said:
I feel very sorry because now I know a lot about prevention-of-mother-to-child-transmission
through counselling and training. I know that among 100 children born by HIV-positive
mothers, only one will be infected. I think that if I had taken preventive medicine, had a
Caesarean section and had bottle-fed the child, it might be not infected with HIV.
However, some women felt at peace with their choice of abortion and soon overcame the
pain it caused. The women who got over the abortion most easily were women who were
already mothers and whose child was still alive. Huyen, for instance, did not feel sorry
about the abortion decision she made because she must concentrate her efforts on caring
for her HIV-positive daughter.
There were differences in abortion decision-making among women: some decided
swiftly while others pondered for a long time before making an ultimate decision.
The decision to end the pregnancy was their own, based on consultations with health staff
and relatives. Often, the women received conicting advice from different people. Most
healthcare providers discouraged women from going through with the pregnancy due to
the high probability of HIV transmission from mother to infant, while family members
expressed different options related to the pregnancy, depending on the conditions of life of
the women and their families.
Most women underwent abortion alone without their husbands involvement. Some
women felt their husbands were too ill to accompany them to health services, while others
concealed their abortion decision from their husbands or partners out of fear that they
would not agree with it. Of the 13 women, only three were accompanied by their husbands
for the abortion. The women felt that problems related to reproduction, including abortion,
are womens issues:
We are women, so things like this fall upon our shoulders. Our men only work, they do not
know our experiences of childbearing. (Van, 27 years old)
In short, all the women in this study opted to undergo an abortion in a situation where they
also fervently desired to have a child. How can we account for this apparent paradox of
women choosing to terminate a pregnancy in a situation where motherhood is strongly
desired?
Maternal responsibility
When we talked about her motivations for terminating her pregnancy even though she
wanted to have a child, Nga said:
I decided to abort because rstly, I fear my child will be infected with HIV. We are HIV-
positive and of course there is a high probability for the child of getting infected. Secondly, in
case my child is HIV-negative, my husband and I fear that we will die early on, when the child
S48 B.K. Chi et al.
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is two or three years old only. I know many people living with HIV who died right after giving
birth. I am sure my parents or parents in law will not abandon our child, but grandparents
cannot replace parents in bringing it up. The child who is an orphan will suffer great misery.
It will die soon. How will my child live? I cannot imagine what it will be like, I only know that
we will be in great misery too. My husband says we cannot forgive ourselves if our child is
HIV-positive due to our selsh desire for becoming parents. We cannot stand this misery.
We cannot bear this child only because of seeing other women giving birth. If I continue my
pregnancy, it means that I gamble with the life of my child.
Nga felt that the future of her unborn child was highly uncertain and precarious. She felt a
strong urge to have a child, but she also expected, as a mother, to be able to protect her
child and ensure that it led a good life. Being HIV-positive, she feared that her child too
would be HIV-infected, having to face disease and death. Even if the child was not
infected, she thought, its future would be in jeopardy as she and her husband might not live
long. The child might end up living in misery and without parents care and love. These
thoughts regarding the future of the unborn child placed Nga in an emotional dilemma
where she had to balance her desires for a child with her worries of being unable to fulll
the responsibility she felt as a potential mother. For her, maternal responsibility was to
bear a healthy child and then take care of the child, bring it up and educate it until mature
age. For Nga, there is no substitute for maternal love and care, even if grandparents are
supportive. She ended up feeling that it would be better for the child not to be born and
decided to terminate her pregnancy.
Ngas thoughts exemplify the concerns of many HIV-positive women in our study.
They felt that becoming a mother meant taking on a large responsibility for bringing up
and educating ones child. Like Nga, the women generally believed that they should not
have a child if they could not rear it. As 36-year-old Huong said:
I was concerned about my own health. I had no economic recources to raise my child. My
sisters or brothers could not take care of my child because they had their own life, they should
bring up their children. My child would become an orphan. I thought for a long time and
I decided to end my pregnancy.
The women did not want to leave their children behind if they died. In this situation, they
thought, the child would become a burden to their family at a time when the family already
lacked economic resources and their parents were growing old. For instance, women said:
I am HIV-positive. If I bear a child, it will be infected with HIV. Also, I am getting weaker and
weaker, I cannot take care of a child and I dont want my child to be a burden for my family
because we are poor. So I cannot have a child. (Lien, 30 years old)
I decided not to give birth. If I have a child, even if it is not infected with HIV, I am not sure if
I can rear it or not when we ourselves are HIV-positive. Our parents will die while we cannot
bring up our child. (Thao, 34 years old)
In spite of the availability of prevention-of-mother-to-child-transmission, most
HIV-positive women feared that not only would their child be sick, it was also likely to
become an orphan, and they could not imagine how it would live without its parents:
He [her partner] desires to have a child but I had to terminate my pregnancy. I feared that my
child would be infected with HIV. And we would not live long enough to take care of our
child. Who can substitute us and care for our child? I dont want our child to become an
orphan. (Hoa, 30 years old)
Many women also worried about the stigma and discrimination that they imagined their
children would have to face. Knowing from their own experience what living with HIV
entails, and sometimes having (had) other children living with HIV, the women feared that
Culture, Health & Sexuality S49
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the child would be stigmatised and excluded in the community. One woman told us about
the challenges that her son was coping with:
Last year my son was at the second grade. He was often sick and had to go to hospital.
The teacher told the other children not to play with him because he was sick. He was also
isolated from his friends because the teacher placed him at a separate desk. I must stand this
discrimination and still let my son go to school. I always warn him not to play with his
classmates and not to scratch or bite them. (Hoa, 30 years old)
For some women, the loss of a previous child who died due to HIV infection was an
agonising pain that kept torturing them. As a mother, they did not want to witness the death
of another child. In other words, many factors, including the uncertainty of the future of
the unborn child; their own status as HIV-infected; and the childs assumed high
probability of being HIV-positive compelled women to opt for a termination of their
pregnancy.
Discussion
The Vietnamese women involved in this study experienced a profound dilemma between
their desire to become mothers and their fear of not being able to fulll what they saw as
their maternal responsibility. Studies from other social settings have documented similar
socially generated conicts between HIV-positive prospective mothers childbearing
desires and their assessments of their capacities to bring up their children (Cooper et al.
2005; Ingram and Hutchinson 2000; Van Hollen 2007). Ingram and Hutchinson (2000)
describe North American HIV-positive womens experiences with reproduction and
mothering in terms of a double bind, arguing that these women are under double social
pressure: childbearing is normatively expected at the same time as HIV-positive people
are considered ill-equipped to have children. HIV-positive women do not feel that they
can choose freely to become pregnant or feel comfortable retaining an existing pregnancy.
The socially imposed pressure to abort haunts them. They feel inadequate if they do not
have children and bad if they do (Ingram and Hutchinson 2000, 130).
Similarly, a number of other studies have shown that it is common for women to hesitate
to have children after an HIV diagnosis (Cooper et al. 2007; De Bruyn 2002; Kirschenbaum
et al. 2004), sometimes despite their stated desires for motherhood (Van Hollen 2007). When
HIV-positive women hesitate to have children, the reasons include, as in the present study,
fears of HIV transmission to their infant (Cooper et al. 2007), fears of the stigma and
discrimination that their children may face (Rutenberg, Biddlecom, and Kaona 2000), a need
to spend economic resources on their own health (De Bruyn 2002), doubts about their ability
to nancially support their children (Cooper et al. 2005; Rutenberg, Biddlecom, and Kaona
2000), fears of leaving their children orphaned (Cooper et al. 2005, 2007; De Bruyn 2002;
Kirshenbaum et al. 2004; Rutenberg, Biddlecom, and Kaona 2000), concerns about their
own health status (De Bruyn 2002; Rutenberg, Biddlecom, and Kaona 2000) and previous
experiences in having a child who was HIV-positive (Cooper et al. 2007). As feminists and
womens health activists have pointed out, HIV-infected women have the right to
reproductive choice; that right includes deciding not to have children for whatever reason
and not be judged negatively for not having children (Zivi 2005). However, in countries with
restrictive abortion laws, access to abortion is limited. Only a few countries have abortion
laws that allow HIV-infected women to terminate their pregnancy (Center for Reproductive
Rights 2002).
HIV-positive women are sometimes deterred from having children because people
in their social environment see HIV-infection as incompatible with parenthood
S50 B.K. Chi et al.
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(Gillespie 2004). Studies have shown that reproduction among HIV-positive women is
sometimes disapproved of by healthcare providers and the negative attitudes of the
healthcare providers toward childbearing put pressure on women to terminate their
pregnancies (Cooper et al. 2005; Ingram and Hutchinson 2000; Kirshenbaum et al. 2004;
Nai-Ying Ko and Muecke 2005). In the present study, most healthcare providers left it to
HIV-positive women and their families themselves to make reproductive decisions, but
they most often warned women of the high risk that their infants would be HIV infected.
Another study from Vietnam quotes a doctor who says that HIV-positive pregnant women
should not have a baby (Oosterhoff et al. 2008, 11), yet this study also points out that the
emphasis in Vietnam on childbearing as culturally mandatory seems to be shared by health
staff, HIV-positive women and families. Health staff, in other words, seem to contribute to
placing HIV-positive women in Vietnam in a double-bind situation where motherhood is
valued yet not encouraged.
For women, the dilemmas are deepened by the fact that motherhood, in many cultures,
is seen as socially mandatory. In many settings, having children is considered basic to a
womans life, a necessary element to complete and fulll her life (Feldman and Maposhere
2003; Ingram and Hutchinson 2000). In East Asian societies, this emphasis on
childbearing is underpinned by Confucian moral ideologies that emphasise the continuity
of the mans family line and fullling the expectation of lial piety to aging parents (Nai-
Ying Ko and Muecke 2005). In Vietnam, children are traditionally seen as expressions of
the good fate ( phuc) of the family (Pham Van Bich 1999), important for marital
happiness and personal fulllment (Johansson et al. 1996; Phinney 2005). As kinship is
patrilineal, sons are regarded as particularly important to continue the family line, care for
old parents and practice ancestor worship (Johansson et al. 1996; Oosterhoff et al. 2008;
Pham van Bich 1999). Research on prevention-of-mother-to-child-transmission in
Vietnam has shown that some HIV-positive women are placed under considerable social
pressure to have a child, as in-laws hope to have a son who will continue the family line
(Oosterhoff et al. 2008). The socio-cultural emphasis on motherhood seems to be
supported not only by traditional moral ideologies, but also by contemporary messages
promoted through the national population and family planning programme. Family
planning messages place strong emphasis on responsible parenthood, underlining parents
and particularly mothers responsibility to care well for their children, ensuring a good
upbringing and education (Gammeltoft 1999; Johansson et al. 1996).
What could be done to help women handle this dilemma? Research from South Africa
has shown that HIV-positive women can be provided with support to cope with
reproductive dilemmas through a supportive healthcare environment where two-way
counselling is offered and where balanced information is given on both the safest way to
have a healthy pregnancy and on possibilities for termination (Cooper et al. 2005).
Similarly, a study from the USA points to non-judgemental healthcare counselling as a
source of support for women (Ingram and Hutchinson 2000). Based on research conducted
in Asia, other authors have suggested that family members such as husbands, parents and
parents-in-law should be involved when information and counselling on reproduction is
provided to HIV-positive women (Oosterhoff et al. 2008).
Conclusion
This study suggests that the concept of child desire is highly complex. Desires for
children are generated within specic social contexts in which expectations are often high
regarding womens abilities to perform well as mothers. Women in this study made
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painful reproductive choices in situations where much was expected of them, while very
limited social and medical support was provided. Our ndings indicate that it is important
that healthcare providers take into account the socio-cultural context that shapes womens
reproductive desires and enter into constructive dialogues with women about their fears
regarding the future and about possible ways of addressing their concerns. When
providing counselling on reproductive choice for HIV-positive women, it is important that
healthcare staff provide accurate information about both the possibilities and the
limitations of new technologies for prevention-of-mother-to-child-transmission of HIV.
In this context, involving family members in the counselling may facilitate womens
decision-making while also helping them to cope with the challenges they face and to
envision alternative ways to become good enough mothers if they opt to keep the
pregnancy.
Acknowledgements
This work was funded by the Danish International Development Assistance (Danida). We would like
to thank all informants who participated in this study and authorities in the study site for their support
during the data collection.
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Resume
A

travers le monde, la maternite chez les femmes seropositives au VIH est une question socialement
controversee. Cet article est tire dun projet de recherche plus important qui a enquete sur les
decisions prises en matiere de reproduction parmi des femmes seropositives au VIH dans le Quang
Ninh, une province septentrionale du Vietnam. Larticle se concentre sur 13 femmes qui ont eu
recours a` un avortement apres avoir ete diagnostiquees seropositives, en explorant leurs reexions,
leurs preoccupations et les dilemmes auxquels elles ont du faire face. Les resultats montrent que ces
femmes cherchaient un equilibre entre leur desir denfanter et leurs inquietudes concernant leur
capacite a` assumer leurs responsabilites de meres. Meme lorsquelles avaient fortement desire
devenir meres, les participantes a` cette etude, craignant de ne pouvoir correctement prendre soin de
lenfant quelles portaient, avaient choisi de mettre un terme a` leur grossesse. Ces resultats indiquent
combien la prise en compte des facteurs socio culturels qui inuencent les choix des femmes en
matiere de reproduction est essentielle pour les conseils dans ce domaine et le soutien apporte aux
femmes seropositives au VIH et a` leur famille.
Resumen
La maternidad entre mujeres seropositivas al VIH es un tema muy polemico desde el punto de vista
social en todo el mundo. Este art culo se basa en un proyecto extenso de investigacion en el que se
analizaron las decisiones reproductivas de mujeres seropositivas en Quang Ninh, una provincia al
Culture, Health & Sexuality S53
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norte de Vietnam. En este art culo analizamos las opiniones, preocupaciones y dilemas de 13
mujeres que abortaron tras haber sido diagnosticadas con el VIH. Los resultados muestran que las
mujeres seropositivas embarazadas deseaban conciliar su deseo de tener hijos con sus
preocupaciones de no ser capaces de cumplir con las responsabilidades de la maternidad. Aun
cuando hay un fuerte deseo de ser madres, las mujeres de este estudio optaron por interrumpir sus
embarazos por temor a no poder cuidar adecuadamente de su hijo. Estos resultados indican que para
ofrecer a las mujeres seropositivas y sus familias asesoramiento y apoyo en materia de la salud
reproductiva, es indispensable tener en cuenta los factores socioculturales que denen las opciones
reproductivas de las mujeres.
S54 B.K. Chi et al.
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