Hanoi (Asia Week): HOA IS A FORMER doctor who has worked 30 years in the maternity ward of a state hospital. Now retired, she lives on her modest government pension -- and on the income generated by her private gynecological center-cum-abortion clinic. As befits a backstreet operation, the clinic is a spartan affair; faded posters of the female anatomy lend a slight professional tone to the simple reception room with a few Lilliputian chairs. In the next room, the operating theater is a picture of war-time austerity, and in the adjacent section is the recovery ward, which is mostly taken up by a king-size bed with a straw mat.
Women -- and often underage girls -- come here for check-ups and pregnancy tests. Of the 200 who visit a month, about 50 have abortions. Hoa (who declines to give her full name) is only licensed for "menstrual regulations" -- a euphemism for abortions done in the first few weeks of pregnancy. But the suspicion is...she is performing later-term abortions too.
The patients can be out on the street in an hour, with virtually no questions asked. They are required to fill out a form giving basic details, but the information is usually not checked and many simply lie. "I know girls who have been here many times, sometimes just a few months after the last time," says Hoa, who also offers counseling on avoiding unwanted pregnancies. With an indulgent laugh, she adds: "They learn their lesson while they are here, but they seem to forget it when with their boyfriends again."
Such "forgetfulness" has contributed to Vietnam having one of the highest rates of abortions in the world. In 1995, public health facilities recorded 1.3 million abortions. Statistics from the mushrooming private sector (including the thousands of operations like Hoa's) are harder to come by, but an estimate by a German expert group working with local authorities puts the total number of abortions at 4 million a year. This would mean abortions outstrip live births by more than 2 to 1 (see chart), far greater than in China or Japan, two other Asian countries with high rates. One international study calculates...the average Vietnamese woman goes through 2.5 abortions in her lifetime. "I was really shocked when I found out," says Erik Palstra, a recently arrived representative of the United Nations Population Fund.
"In traditional thinking, a fetus is a living thing, so when you have an abortion, there are bad psychological consequences," says sociologist Khuat Thu Hong of the National Center for Social Sciences. So why the high abortion rate? Part of the reason is demographics. The post-war "baby-boom" generation is...reaching reproductive age. As the country opens up and mores change, young Vietnamese are indulging in sexual activity as never before. Having a baby out of wedlock is a big stigma, leading to a steep rise in pregnancy terminations in recent years.
...unmarried women are thought to account for just 30% of abortions, meaning the problem is broader. Family-planning experts point to the lack of contraceptive options. "The choice is very limited while abortion services are available everywhere, so many women find it easier to have abortions than to use birth control," says Khuat.
When it comes to contraception, many Vietnamese still opt for traditional techniques like rhythm and withdrawal. Among those using modern methods, there is a heavy reliance on IUDs, which tend to have a high failure rate because they are often inserted improperly. Misundertandings about the pill are widespread, even among the medical profession (the main one is...it causes cancer). And then there is the universal problem of getting men to accept condoms. "Vietnam is roughly where Bangladesh was in 1981 in terms of modern methods of contraceptives," says Palstra.
Given the extensive public health infrastructure and the high literacy and social status of Vietnamese women, experts say the country should not have such a high abortion rate. To bring it down, health officials are now looking for more international assistance -- critical in Vietnam's implementation of its highly successful immunization program.
Another necessary step is to remove the profit motive. Three abortion procedures are the equivalent of one medium-degree surgery, and entitle health-care workers to extra pay. "Officials must change the system so there is no longer a financial incentive for the service providers," says one international expert.
For Hoa, money is no longer an attraction. Even though the clinic earns her several times her pension, she says she has seen enough. In the past, the consent of the husband and a local ward official was required before a woman could have an abortion, and Hoa advocates returning to such strict guidelines. But that, she concedes, is as likely to happen as a Vietnamese girl choosing to give birth to her illegitimate baby.