Abortions amongst Asian Women in New Zealand: What Do We Know? Lien Thi Thuy Trinh A thesis submitted for the degree of Masters of Public Health at the University of Otago, Dunedin, New Zealand 26th September 2012 Dedication To millions of unborn children. To all the women who have to make heart-aching decisions at some point in their lives. To the late Associate Professor Oliver Davidson who left us before his time. i EXECUTIVE SUMMARY The aim of this thesis is to identify the current situation and underlying factors related to abortion among Asian women in New Zealand. The thesis’s objectives are to investigate the current abortion situation among Asian women in New Zealand (number, rate, ratio, demographics) and to identify underlying factors in relation with abortion among Asian women in New Zealand. It consists of two components: i) An epidemiological study of abortion trends and patterns among Asian women in New Zealand analysing the routine abortion data during the period between 2002 and 2008 (both published and unpublished) provided by the Statistics New Zealand; and ii) A cross-sectional study of 188 self-identified Asian women who presented for abortion at four selected abortion clinics in New Zealand. Results from the routine abortion data showed that Asian women had the highest abortion rates and ratios between 2002 and 2008 in comparison with women of other ethnic groups. Abortions among Asian women in their 20s accounted for more than half of the total abortion number for the period of 2002-2008. Asian women obtaining abortions were getting older over time. Between 1998 and 2003, when abortion number by women’s marital status were gathered, data show that abortion numbers were higher among Asian married and previously married women. Women who were born in China (including Hong Kong) had far more abortions than all the women born in other top-five countries (Fiji, India, South Korea and Japan) added altogether. The number of abortions among women born in China accounted for nearly half of the total number of abortions among Asian women in all years in this period. More than half of the Asian women obtaining abortions who were not born in New Zealand arrived in New Zealand within five years, between 2001 and 2005. Asian women, particularly Chinese women, also reported very low percentages of oral contraceptive failure across the years, probably reflecting low use. Findings from the cross-sectional survey showed that the typical Asian woman within the studied sample having an abortion was in her 20s, married or co-habiting with a partner, had no children, had no previous abortion, was highly educated, and did not belong to any religious background. There were a large number of women obtaining abortions who belonged to the Chinese ethnic group, as well as a large number of non-citizens who were ii born in China or of Chinese nationality, reflecting the findings from the routine data. The majority of women who were not born in New Zealand had arrived in the country in the past 10 years with more women who arrived in the last 5 years. About half of the women presenting for abortion were students, the majority studying at tertiary level. The main reason for an abortion was having a baby now would dramatically change the women’s life; that is, having a baby would interfere with education or work, or would interfere with the responsibility of caring for other dependents. Nearly two-thirds of the participants indicated that they could not afford to have a child now. Single motherhood or relationship problems were also among reasons for abortion, as well as several other factors such as completed childbearing and pressure from parents. About three-quarter of the Asian women specified that their husband or partner helped them decide to get an abortion. The results show that only about one third of the participants thought that a woman should be able to obtain an abortion if she wanted it for any reason. Less than a quarter of the women claimed that they had used a birth control method all the time. The fear of side effects was the most common reason for non-use or infrequent use. The fear of gaining weight when taking birth control pills was the main concern, followed by women’s ambivalence about the pills. More than half of the women had heard of emergency contraceptive pills (ECPs) and nearly two thirds correctly thought that ECPs are used to prevent pregnancy. At least one in five women who had heard of the pills but did not know what they were used for, or had never heard of the pills. Results from the analysis of abortion clinic surveys provide insights into the topic of unwanted pregnancy and abortion among Asian women in New Zealand at multiple levels. Individual cognitive, psychological and socio-economical, as well environment factors contributed to the women’s decision. More specifically, as well the women’s psychological perspectives as why an abortion is needed, the attitudes towards abortion and unwanted pregnancy, and the living condition and/or situation influenced the decision. The study also provides better understanding of Asian women’s sexual health knowledge, attitude and behaviour, that includes the knowledge and use of contraceptive. The study results not only addresses the original research questions, but also supports a number of hypotheses generated from the routine data analyses and the review of literature in terms of, for example, iii contraceptive use at conception, decision-making process, and sexual and reproductive health knowledge and behaviour. It is hoped that this study will positively contribute to the body of research knowledge in terms of the topic of unwanted/unplanned pregnancy and abortion among Asian women in New Zealand, and help guide the development of effective sexual and reproductive health programmes for Asian migrant women and their partners, improving their knowledge, attitude and behaviour toward safe sex, resulting in fewer unwanted pregnancies. iv ACKNOWLEDGEMENTS I wish to thank all the participants who were willing to pour out your thoughts and feelings, even in a confined medium such as the survey questionnaire. I am grateful to all the consultants, nurses, and staff at the four abortion clinics where the survey was conducted. Despite your busy daily schedule, you were eager to help. Without your willingness, this research would not have been possible. I am deeply thankful to my supervisors, Associate Professor Nigel Dickson, Dr. Kumari Fernando, Emeritus Professor Charlotte Paul, and Dr. Sheila Williams. Being a mature student is not easy; but it would have been a much more difficult journey if I had not received wonderful support, guidance, and enormous patience from my supervisors. I wish to thank all the administrative staff at the Department of Preventive and Social Medicine for your kind support during my studies at the Department. I want to thank Catherine, Debbie, Judith, Nicola, and Susan for being there for me even at the last minute. I am grateful for all the practical and financial support that the university and both the departments extended to me during my studies. I am also thankful for the friendship formed along the way with many students and colleagues at the university. I am most thankful for my family for your encouragement through the ups and downs of the postgraduate student life. I am thankful for my husband James who, many times, stayed up late into the night and the early hours to keep me company when I needed to pull an all- nighter. I am grateful for my son Jayden who never ceased to pray for my thesis completion. v TABLE OF CONTENTS Page Dedication ………………………………………………………..……………………… i Executive Summary …………………………………………..………………………… ii Acknowledgements ........................................................................................................... v Table of contents ............................................................................................................... vi List of tables ...................................................................................................................... xii List of figures .................................................................................................................... xv Chapter 1: INTRODUCTION ……………………………………………………………….. 1 Chapter 2: LITERATURE REVIEW ………………………………………………………... 3 2.1 Unwanted Pregnancies and Abortion: An Overview of Theoretical Frameworks …... 3 2.1.1 Why Do Women Have Unwanted Pregnancies? ……………………………... 3 2.1.2 Why Do Women Have Abortions? …………………………………………… 11 2.2 Unwanted Pregnancies and Abortion in Asia: Perception, Attitudes, Politics and Religion ………………………………………………………………………………….. 15 2.2.1 Moral Values …………………………………………………………………. 16 2.2.2 Abortion, Unwanted Pregnancy and Buddhism ……………………………… 19 2.2.3 Birth Control Policies and Sex-selected Abortion Trend …………………….. 20 2.3 Sexual And Reproductive Health Among Asian Population: A World Review Of Empirical Studies ………………………………………………………………………… 24 2.3.1 Literature Search Strategy ……………………………………………………. 24 a. Style …………………………………………………………………………… 25 b. Resources ……………………………………………………………………... 25 c. Key Words and Phrases ………………………………………………………. 25 d. Outcome ………………………………………………………………………. 26 2.3.2 Findings from the Literature Review: Level of Knowledge, Attitude, and Behaviour among Asian population ………………………………………………… 26 2.3.3 Findings from the Literature Review: Level of Knowledge, Attitude, and Behaviour – A Special Focus on Youth in Asia ……………………………………. 30 2.3.3a SRH Knowledge and Sources