Ho Chi Minh City, Vietnam - Two decades ago, still impoverished and reeling from the effects of the US war, Vietnam's Ministry of Health attempted to tackle the country's unchecked population growth, imposing a two-child rule among families and providing legal abortion to married women free of charge.
Today, despite having greater access to contraception and reproductive health services, abortion rates in Vietnam are the highest in Asia and among the highest in the world.
According to doctors from Hanoi's Central Obstetrics Hospital, who presented a report last May at the Franco-Vietnam Gynaecology and Obstetrics Conference, 40 percent of all pregnancies in Vietnam are terminated each year.
Abortions in the first 22 weeks are still legal, affordable and available upon request at public hospitals and private health facilities across the country. According to the United Nations Population Fund (UNFPA) Compendium of Research on Reproductive Health in Vietnam, two-thirds of terminations in Vietnam today are a result of unwanted pregnancy.
The case for counselling
Public service providers [in Vietnam] are all trained in family planning counselling but they just don't have time.
Family planning campaigns have made strong progress in providing Vietnamese women with access to modern contraceptive methods. UNFPA data found that 78 percent of married women use some form of contraception. However, the research also reported that, of married women seeking abortions in Vietnam, around two-thirds had used some form of contraception.
"If family planning use is high and abortion is high, too, then you probably have to assume that something goes wrong in between the use and actually having an abortion," Arthur Erken, UNFPA representative in Vietnam, told Al Jazeera.
For married women seeking contraception, particularly in public health facilities, several modern methods are available. However, the sheer volume of patients often forces healthcare providers to skip family planning counselling. For health officials hoping to reduce the country's annual abortion rate, this guidance is key.
"The only answer is the quality of counselling and following up," Nguyen Thi Bich Hang, chief representative of Marie Stopes International (MSI) in Vietnam, a global family planning organization that provides reproductive health services to women in underserved areas, told Al Jazeera. "Public service providers [in Vietnam] are all trained in family planning counselling but they just don't have time."
Without counselling, Hang said, women are more inclined to stop using contraception over time. According to MSI research, she said, only one percent of women who sought an intrauterine device at an MSI clinic discontinued using the contraception at 12 months. Within the public sector, the rate was as high as 12.5 percent.
"Phuong", a 36-year-old married woman in Ho Chi Minh City, who asked Al Jazeera not to use her real name due to the sensitivity of the subject, said this lack of counselling rings true. Though she has, in the past, spoken to a doctor about contraception, the majority of Phuong's knowledge about family planning is gleaned from books and the Internet.
"I just find out on my own," she said. The communications professional, who is married with two children, considers abortion unethical and would not personally terminate a pregnancy. However she understands that other women, particularly young girls, might be in more complicated circumstances.
"I think some people will be in a very difficult situation," she said, "but I still think it's unethical."
Sex before marriage
While married women struggle to receive proper counselling, current family planning campaigns fail to address the growing number of young Vietnamese who are sexually active before marriage.
Young people who are sexually active have to go to the private sector, often with a lack of proper information.
In Vietnam's conservative culture, premarital sex is considered taboo. Women who become pregnant out of wedlock face strong social and familial repercussions. As a result, many unmarried women choose to seek abortions at private clinics.
While these facilities provide greater anonymity to their patients, government statistics only account for abortions performed in public health facilities, excluding most young, unwed women from the official data. According to UNFPA's research, one-third of abortions performed in urban areas involved young, unmarried women, however Erken estimates that the actual number of abortions among this population is much higher.
"I have a feeling actually that [abortion] is quite high among unmarried young people," Erken said. "The official family planning program doesn't target them, so young people who are sexually active have to go to the private sector, often with a lack of proper information."
For Nguyen Tuong Vi, 21, abortion is unethical, but also justifiable in the case of young, unmarried women, especially adolescents.
"Two or three years ago, if I was pregnant I would have [had an abortion]," said Vi, who is sexually active and unmarried. "I was still young, I didn't have a career; I don't feel like I would have been able to take care of it."
If faced with the situation now, Vi, who does not use contraception with her boyfriend, says she would keep the baby. Still, she knows that the familial consequences of having a child out of wedlock would be severe.
"Definitely, they'd be very angry," she said. "My mother would be very worried about what other people would think. They'd think she didn't raise her daughter properly."
Like many young Vietnamese, Vi never received any formal sex education in school. With her parents, too, discussing safe sex is out of the question and the social stigma of visiting a reproductive health facility as an unmarried woman means that she has never sought family planning counselling on her own. Instead, Vi gets her information from friends and from the Internet.
"There's quite a lot of need in terms of reproductive health knowledge to young people," said Le Ngoc Bao, country representative of Pathfinder International, a global non-profit organisation that works closely with Vietnam's Ministry of Health in the area of adolescent reproductive health. "For quite a long time the sex education, the desires of intervention for youth in the school continue to be at the pilot scale."
While the Ministry of Health has begun to recognise the need for sex education in schools, traditional values make it difficult for teachers to discuss these issues with students. Across the country, a handful of schools are beginning to take a proactive stance in educating adolescent students but parents and teachers remain hesitant to broach the topic.
"Parents now see the need to have sex education introduced into some formal setting," said Bao, "but the question they are still asking is to what grade should the content be introduced."
After years of positive change, growing access to contraception and improved medical facilities, Vietnam finds itself at a roadblock. While contraception is widely available and reproductive health services open to married women, improvement of family planning counselling remains an obstacle. And as the number of sexually active unmarried Vietnamese continues to rise, public health officials struggle with the unfinished business of introducing sex education into a conservative society.
"For me, I think this is the issue for Vietnam," Erken said. "The government is aware that this is an issue that leads to certain problems, but the problem for them is, of course, that it's still a conservative country. It's still difficult to open up the public facilities entirely for this. Knowing something doesn't mean that you're willing to act on it."