Julaporn Srinha
HIV-infected pregnant women and abortion
Introduction
HIV infection and AIDS among Thailand women have increased over the last
decade, so the number of HIV-infected pregnant women have increased also. Because
HIV can be transmitted from mother to child, this is a big problem when the mother
dies, the child becomes orphan. Women can become HIV infected by several way
including sexual contact with infected person, by sharing needles and/or syringes with
someone who is infected (drug user), or through transfusions of infected blood or
clotting factor (very rarely in Thailand is the blood screened for HIV). Women who
are sex workers are at risk to get HIV from infected man when she has unsafe sexual
intercourse. But in housewives infection mainly come from husband. For example it
was found that 95% of 40 HIV infected mothers delivering at a famous hospital in
Bangkok, got the disease from husbands who lead a risky life without using condom.
The risk of HIV transmission in women is increased if they have a unrecognized and
untreated sexually transmitted disease(STD), and by low status and inability to
negotiate safer sex. This is further complicated their by in adequate access to
information and condoms.
One option for HIV injected pregnant women is to get an abortion. The
definition of abortion is “expulsion of the of the fetus from the womb during the first
28 weeks of pregnancy”, that mean “induced abortion “ from physician in the case of
HIV-infected pregnant woman. The present abortion laws according to the Thai Penal
Code section 305, hold that abortion is illegal except in two cases. In the first case, a
women is allowed to have an abortion when the health of the mother dose not permit
her to give birth or when the pregnancy threatens her life such as heart failure. The
second case is when the woman is raped or deceived into having intercourse. Thus
Thailand’s abortion legislation is very restrictive. So abortion in HIV-infected
pregnant women is illegal. In general difference of attitude and opinion toward
abortions come from different socio-economic and demographic characteristics (for
example age, education, occupation, number of living children, ideal family size
,family status). However, in Thailand the society disagree with abortion for moral
reason. For example (Kamkom, 1997) in a study involving 704 female vocational
students in Bangkok indicated that more than 87.2 % of the females showed their low
tendency to obtain an abortion and factors related to obtain an abortion are concern
with unwanted pregnancy, sexual transmitted diseases, economic status, rape and so
on. In Buddhism, we have 5 silas that is fundamental rule for Buddhists. So in
Buddhism anyone who commits an abortion in violates the first silas(do not kill
living-thing) and inevitable this will lead to suffering in the present or next life.
Another report Prajayayothin,1996 that investigated in 727 students ages between 15
to 24 years old in Bangkok, it was found that more than 80% of youth in this study do
not prefer to abortion method, otherwise the students may be changed the opinion
when the pregnant women have a risk cause for her health.
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Mother to child transmission
Up until now the number of infants who acquire the virus is rising rapidly in
Thailand. The risk of a baby acquiring the virus from an infected mother ranges from
15% to 25% in industrialized (developed) countries and 25% to 35% in developing
countries. On an average, one-third of children born to HIV-infected mothers will
become infected themselves. Lower rates in developed countries may be because of a
number factors, including the availability antiretroviral treatment of HIV-positive
pregnant women. Higher rates in developing countries may be because of poorly
nutritional and immune status. Therefor higher rates of sexually transmitted diseases
among women in these countries.
It is also not clear why some babies of HIV-positive women are infected while
others are not. In general the transmission can occur in antenatal(during pregnancy),
perinatal (delivery) or/and postnatal (breastfeeding) periods. During pregnancy period
nobody know “Whether HIV infected will occur or not?” In addition HIV can find in
amniotic fluid and placenta . Viscarello et al ,1992 studied serum and amniotic fluid
obtained 13 seropositive (HIV positive) women before elective termination of
pregnancy by using Enzyme-linked immunosorbent assay(ELISA), western blot
antibody, p24 antigen assays. The p24 antigen was found in the maternal serum and
amniotic fluid from 5 of 13 women(38%) and in serum from only 3 of 13 (23%).
Since HIV was found in vaginal fluid, during delivery as a baby is exposed to
maternal blood and secretions while passing through the birth canal. It appears that the
time this period to contact in vaginal canal and cervix may be very important for HIV
transmission. Because of HIV can be found, milk breastfeeding can also promote in
HIV transmission.
The baby can become infected at any point from early pregnancy until the end
of breastfeeding. It is though that about a third of mother-to child transmission occurs
during pregnancy, and about two-thirds around the time of delivery and afterwards.
Figures for the proportion of babies infected during breastfeeding vary, but on an
average it is though that breastfeeding is responsible for 14% of mother-to-child
transmission. However the risk of HIV transmission from mother to child appears to
be high for a recently infected mother who has high virus in the blood and other body
fluid. Analysis of a number of studies of breastfeeding and HIV found that the
transmission rate was around 14% from mother who were already HIV positive at the
delivery but the rate of transmission from mothers who were infected after delivery
and during the breastfeeding period was 29%. In addition a woman who has more
advanced HIV disease also has a higher viral load and the risk of HIV transmission to
the baby during pregnancy, birth or breastfeeding to be higher. The low birth weight
and premature babies have higher rate of infection may be because their immune
systems are not fully developed and they are less able to fight off HIV. Sometime if
the mother has severe vitamin A deficiency, it appears that the transmission is greater
than normal. Thereby suggestion that nutritional deficiency also play a role in HIV
infection.
Preventing mother-to-child transmission of HIV
The most effective intervention to reduce mother-to-child transmission is
preventing infection in women before and during pregnancy, in perinatal period and
while they are breastfeeding. This is very important, not only for the health of the
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mother but also for the baby. Most women find out that they have HIV during
pregnancy. Antiretroviral therapy have been used to reduce the transmission from
mother to child. In the study of Mauskopf, 1996 (ACTG Protocol 076 in Thailand) the
HIV transmission rate in AZT-treated (zidovudine) pregnant women reduced
significantly (25.5% to 8.3%). Beside, treatment costs for HIV-positive pregnant
women and their newborns also reduced depending on the reduction of transmission
rate. Research at Beth Israel Deaconess Medical Center in Boston has found that 24
pregnant women whom received zidovudine during last trimester, 7 of 24 (29%)
women transmitted HIV to their babies. Some trail, in 414 women when received
zidovudine during pregnancy, 10.6% gave birth to have infected babies during vaginal
delivery and 1.7% during cesarean, so cesarean may help reduce HIV transmission.
HIV-positive women are advised not to breastfeed as it appear that babies are at risk
when braestfeed by HIV-positive mothers. Putting this recommendation into practice
is not easy because breastfeeding protects babies against other infections. In addition,
formula and animal milk are expensive. It appear that breastfeeding is the only option
for HIV infected women in areas where infectious disease and malnutrtion are the
main cause of infant deaths and where infant mortality is high. This is because a
baby’s risk of HIV infection from breast milk is likely to be lower than its risk of
death from infectious diseases. In Thailand HIV-positive women are recommended to
use formula or animal milk.
Decision to continue or terminate pregnancy in
HIV-infected pregnant woman
The numbers of people who decide to have an abortion or continue pregnancy
appear to vary. Example Selwyn et al,1989 studied among intravenous drug users and
found that 14 of 28 (50%) HIV-positive chose to terminate their pregnancies.
Sunderland et al,1992 studied and found that 6 of 32 (18.8%) seropositive women
chose abortion. The first research Chaiprasitti, 1994 from Thailand on in-depth
interviews of 9 HIV-infected women. It was found that 4 women (44.4%) decided
abortion while, 5 women (55.6%) decided to continue their pregnancies. The process
of decision making was complicated. Not only medical factors, but also social factors
highly influenced the decision-making process. These factor were perception and
understanding of medical information from their counselor, perceived severity of
AIDS and expectation of the magnitude of problems that would occur to them and
their families, the economic status of their families and the ability of afford future
expenses and their status or power within their families. The second report from
Kongsakron, 1995 in 20 HIV-positive, in one of hospital. While four of them (20%)
decided to terminate pregnancy but eighteen (80%) mother who continued their
pregnancy set priority to other factors such as strong desire for children, take a chance
of risk in virus, transmission rely on their healthy, status. Besides this, it was found
that factor and to against terminating pregnancy included husband’s choice, gestation
age and limitation of medical service. A survey research from Auttagovit, 1995
consist of 154 case of HIV-infected pregnant women in Petchaburi province. About
38 case (24.7%) decided to terminate pregnancy and while 116 (75.3%) continued
pregnancy. A descriptive study by Teanchai, 1996 involved 150 HIV infected
pregnant women in the 7 government hospitals, of 6 provinces in the upper northern
part of Thailand. About 38% of the HIV infected pregnant women infected to have an
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abortion. There were nine factor; perception of severity of HIV infection in mother
infant, education, religion, husband’s perception of his wife in HIV infection,
perception of abortion age at marriage, domicile, economic status of the relatives, and
tangible support from the husband significantly discriminate the HIV infected
pregnant women’s intention. Among three factor; the perception of HIV infection in
the mother/infant ,domicile, economic status of the relatives were very powerful
factors. Above of all that show many different factors play a role in the decision vary.
Children with HIV often have the same illness as children without HIV, but
these may be more serious, frequent or difficult to treat. About 4 in 10 infected
children die by the age of 12 months, many survive beyond two years of age, and
some have reached adolescence. In addition to children who are living with HIVinfected parents who are either sick or dying there are many children who have been
orphaned by AIDS. They may have lost a mother or a father or both. In Thailand, over
200,000 children-a third of them under five-are expected to lose their mothers because
of AIDS by 2005. Loss of a patent or parents can affect young children in many way.
The effect vary from country to country and depend on culture social and family
structures, and grandparents or older sibling who are unable to cope or to afford extra
food and clothing. Children from families affected by HIV and AIDS may be
stigmatized and rejected and not allowed to play with other children. In addition the
health of children under fives who do not have a mother is generally worse than that
of those who do. The mother have relied on to bring a child for immunization ,to seek
treatment for children illness and to ensure that a child is well nourished. Not on the
healthy but also economic problem in HIV families, because treatment costs are too
expensive for them to pay. Although physician treat HIV patients, in a recent survey it
was found that most were unwilling to take care of AIDS/HIV positive patients most
expressed fear in risk when working with AIDS/HIV positive patient (YEE, 1991).
String et al,1999, studied 480 Thai physicians it was found that many physicians were
unwilling to perform pelvic examinations (19.2%) ,vaginal deliveries (30.7%) or
cesarean deliveries (39.5%) on women who were know to be infected with HIV.
Above all it found that when the women decided to continue pregnancy, she faced
with several problem such as to depression and the future of herself, her husband and
her baby, her economic situation, discrimination from relatives and families. Women,
who decided to have an abortion, the issues include side effect or danger from
abortion especially in illegal hospital or clinic. Women ask the question “Is it deadly
sin? Or Was I a sinner? Because in Buddhism a major rule for life is: do not kill
living thing ; it a sin. So both of HIV-infected pregnant women have a problem and
received the effect from these problem sometime the same sometime different.
The appropriate way for these problem in Thailand
First of all preventing infection in women is better in many ways than
treatment so options are everyone in their society have responded for prevention for
avoid risk of HIV infection. So educating people about HIV/AIDS prevention is very
necessary. Advocacy for women in HIV screening test are very important to families
to planing in the future. However when the women have HIV infection and pregnancy
also. Physician would like to give correct data for pregnant women and her husband,
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her families or relatives, neighbor and people involved in support group to support
both body health and spirit health. If she decided to keep her baby the government
must have a system for them so that antiretroviral therapy (if it can prove clearly in
cost effective and toxicity), power milk for child are available, In Thailand, if a
mother cannot pay for powder milk the government service for 1 year age . In addition
long term service is necessary since they are HIV-positive. Counselor service is very
important to support the women. After parents died, the orphans would like to receive
the service from families and government like another orphans. In Thailand
HIV/AIDS is a national level problem and we received the help from several
organization in the world. The budget paying in this problem is very high, about
1400,000,000 bahts in 1999 and about 1,000,000,000 bahts (72%) use in servicing
,treatment and counseling of HIV/AIDS patients. Above all when we return to the
question “ A pregnant women’s right to choose to abortion when she have HIV
infection ? This question is too difficult to answer. In some situation, you cannot
decide they to be right or wrong, black or white. Similarly, you can not conclude if a
pregnant women deciding to have abortion is wrong or right.
Conclusion
The HIV-infected pregnant women decide to continue or terminate pregnancy
is the complex process, however more than 50% of women would like to continue
pregnancy. Many factor play a role such as the data about disease from physician,
belief, religion, her husband, her relatives or families, economic and social. when
women conclude the factor after that she decided it . Mainly, women who decided to
keep the baby, face longer and more serious problems than the one who terminate
their pregnancies. Everybody would like to agree with a women’s decision and
support her health both body and spirit health. In this situation you can not conclude
pregnant woman decides to abort is wrong or right. It is her decision. We would like
to support them as against judge them.
References
1. Auttagovit P, 1995. Decision to Continue or Terminate Pregnancy in HIVinfected Pregnant Women. MD Thesis. Faculty of Science (Human
Reproduction and Population Planing), Mahidol University.(Thai)
2. Chaiprasitti S, 1994. Decision-Making Process in Maintaining Pregnancy
of HIV-infected Women. MD Thesis. Faculty of Arts (Medical and Health
Social Sciences), Mahidol University.(Thai)
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3. Cheasawan N, 1996. Life and Knowledge about AIDS in the HIV infected
Mothers. MD Thesis. Faculty of Arts (Cultural Studies),Mahidol
University.(Thai)
4. Kamkorn P, 1997. Cognitive factors related to the Tendency to Obtain an
Abortion among Female Vocational Students in Bangkok. MD Thesis.
Faculty of Arts (Medical and Health Social Science ),Mahidol
University.(Thai)
5. Kongsakorn K, 1995. The process of Decision to Continue Pregnancy in
HIV Infected Pregnant Women. MD Thesis. Faculty of Nursing (Maternity
and Newborn Nursing).(Thai)
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8. Selwyn PA et al 1989.Knowledge of HIV Antibody Status and decision to
Continue or Terminate Pregnancy among Intravenous Drug Users. JAMA.
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9. String JS et al, 1999. Prevention of Mother-to-child Transmission of HIV
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11. Teanchai S, 1996. Factors Affecting Firstly Known HIV infected Pregnant
Women’s Intention to have an Abortion in 6 Provinces in Upper Northern
Part of Thailand. Ph.D. Thesis. Faculty of Education (Population
Education), Mahidol University.(Thai)
12. Viscarello RR et al 1992. Fetal Blood Sampling in Human
Immunodeficiency Virus Seropositive Women before Elective
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