Vietnam

Disclaimer: Some of the MDG data presented in this website have been adjusted by the responsible specialized agencies to ensure international comparability, in compliance with their shared mandate to assess progress towards the MDGs at the regional and global levels.^[1] 

 

Indicators (United Nations)

 

5.1 Maternal mortality ratio (MMR):

a.    2000: 130[2]

b.    2005: 150[3]

c.    2005-8:

A maternal death is “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration or site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental causes.”^[4] According to the 2005 WHO/UNICEF/UNFPA maternal mortality estimates, most of the countries in the Asian region have not reduced the maternal mortality by three quarters as stated in the MDG Goal.^[5] 

Viet Nam records a high maternal mortality ratio of 150 per 100,000 live births in 2005^[6]. 

 Based on the Viet Nam ICPD+15 study submitted to ARROW by our partner, ( Center for Creative Initiatives in Health and Population-CCIHP), Vietnam a study in Vietnam on maternal mortality by WHO^[7],  found that direct and indirect causes of mortalities accounted for 76.3% and 23.7% respectively. The direct causes were haemorrhage, 41%, pre-eclampsia 21.3%, infection 16.6%, complications of abortion 11.5%, uterine rupture 4.7%, and ruptured ectopic pregnancy 4.8%. Indirect causes of maternal mortality were: heart disease 26.3%, hepatitis 10.3%, cerebro-vascular diseases 10.7%, tuberculosis 10.5% and malaria 15.3%. Other causes that were related to a maternal death were asthma, poisoning, malaria, cancer, mental disorders and encephalitis. There is little accurate information or data on maternal morbidity such as obstetric fistula in Viet Nam.

 

Critical indicators to comprehensively monitor maternal mortality

 

5.1.1 Lifetime Risk of Maternal Death

The concept of adult lifetime risk of maternal death measured as the probability of dying from a maternal cause during a woman’s reproductive lifespan^[8], is more holistic in comparison to maternal mortality ratio (MM Ratio) and maternal mortality rate (MM Rate). Whereas the MMRatio and the MMRate are measures of the frequency of maternal death in relation to the number of live births or to the female population of reproductive age, the lifetime risk of maternal mortality describes the cumulative loss of human life due to maternal death over the female life course. Because it is expressed in terms of the female life course, the lifetime risk is often preferred to the MMRatio or MMRate as a summary measure of the impact of maternal mortality^[9].

 

The lifetime risk of maternal death is 1 in 48 in Viet Nam, as compared to 1 in 1 300 in China, which shows the extent of risk to the life and well being of Vietnamese women in reproductive age group, which is indicative of inequity.

 

5.1.2 Maternal deaths due to unsafe abortion

 

The incidence of unsafe abortion is negligible in Viet Nam as abortion is legal and relatively accessible.^[10] 

 

5.2 Proportion of births attended by skilled health personnel:

 

a.    2000: 69.6^[11]

b.    2006: 87.7^[12]

c.    2005-8:

 

A skilled attendant, according to WHO, refers to “an accredited health professional-such as a midwife, doctor or nurse- who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns.” Traditional Birth attendants (TBA) either trained or untrained are excluded from the category of skilled health workers.

Skilled attendants at birth in 2005 in Viet Nam were reported to be 87.7 in 2006^[13].

Based on the Viet Nam ICPD+15 study submitted to ARROW by our partner, (Center for Creative Initiatives in Health and Population-CCIHP), Vietnam, by 2002, 85 percent of births are delivered under the supervision of a doctor (49.7%) or nurse or midwife (35.3%)^[14]. This is a significant change as in 1997 birth attendance by doctors was only 27%^[15], while births attended by nurses and midwives were 50.1%. Traditional birth attendants assist in the delivery of 5.3% of births, while another 9.5% percent of births are assisted by relatives and others^[16].Teenagers are more likely to have received delivery assistance from a relative or friend than older women, who are more likely to have been assisted by a doctor. First births are also more frequently delivered under a doctor’s supervision than higher order births. Urban women are much more likely than rural women to receive the benefit of medical supervision during delivery; Births in urban areas are more than twice as likely to be delivered with the assistance of a doctor as in rural areas. Also, as the differentials in place of delivery would suggest, higher educated women and women living in the Southeast region are much more likely to have the advantage of a medically-supervised delivery. Northern mountainous areas has highest number of birth assisted by relatives (37.3%) and also highest percentage of birth at home^[17] (56.1%).

 

Critical indicators to comprehensively monitor skilled health attendance would include not just skilled birth attendants but also access to basic and comprehensive emergency obstetric care services and post-partum care 

The quality of care provided by skilled attendants at birth is crucial. Particularly when complications occur, skilled personnel need access to essential drugs, supplies, equipment and emergency obstetric care. They should receive training on required competencies. And they need supervision that helps ensure high standards of care, which is vitally important^[18]. 

Global and country studies on skilled attendants showed that the overall effectiveness of skilled attendants depends on their access to a functioning health system with a basic and comprehensive level of obstetric care, including surgery and blood transfusions in case of complications. The key to maternal death reduction is universal access to emergency obstetric care which is a major challenge in most of the Asian countries.

It is therefore critical to not just look at skilled attendants at birth, but also look at a) access to emergency obstetric care services and b) postpartum care so as to reduce maternal deaths meaningfully.

5.2.1 Access to emergency obstetric care

One other study carried out by Save the Children/USA and the Ministry of Health in Vietnam between 2001 and 2004 was intended to improve the availability of access to and the quality and utilisation of emergency obstetric care services in district and provincial hospitals in two provinces in Vietnam. The “project improved the functional capacity of three provincial and one district hospitals providing comprehensive EmOC services, and upgraded one district hospital providing basic EmOC into comprehensive EmOC facility through training, infrastructure and quality improvement. Results of the project showed that more women used the health facilities and their conditions were managed.”^[19]

 

5.2.2 Post partum care

 

A large proportion of maternal deaths occur during the 24 hours after delivery and hence postnatal care constitutes a critical safe pregnancy intervention. The first two days following delivery are critical for monitoring complications arising from the delivery.

 

The single most common cause of maternal mortality is obstetric haemorrhage, generally occurring postpartum and accounting for 25—33% of all maternal deaths. The rate of death due to post partum haemorrhage (PPH) varies widely in the developing world. PPH-related mortality rates based on hospital studies are estimated to be 25—30% in India, and 43% in Indonesia. However, women who come to a hospital for care do not represent the general population of women. Because haemorrhage is more apt to occur and more difficult to treat in the community, studies have suggested higher rates of PPH-related mortality in these areas, but there is comparatively little data available outside of a hospital setting.^[20] 

 

5.3 Adolescent birth rate (per 1000 women):

a.    2000: 25.0^[21]

b.    2005: 30.0^[22]

c.    2007: 35.0^[23]

 

The adolescent birth rate measures the annual number of births to women 15 to 19 years of age per 1,000 women in that age group. It represents the risk of childbearing among adolescent women 15 to 19 years of age. It is also referred to as the age-specific fertility rate for women aged 15-19^[24].

 

The adolescent birth rate in Viet Nam increased from 25 per 1000 women in 2000 to 35 in 2007.

 

Based on the Viet Nam ICPD+15 study submitted to ARROW by our partner, (Center for Creative Initiatives in Health and Population-CCIHP), Vietnam, there are significant differences in the level of teenage childbearing by residence. The level in rural areas 3.7% is double the level in urban areas (1.6%). By region, the percentage of teenage childbearing varies from 1.8% in the Central Highlands to 4.8% in the Central Coast. Teenage childbearing is strongly and inversely related to level of education. Teenage childbearing is highest among women with some primary education (10%), substantially lower among women who have completed lower secondary school (1.9%), and lowest among those who have completed higher secondary school (less than one percent. ^[25] 

 

Teenage fertility and pregnancies are a major health concern because teenage mothers and their children are at high risk of reproductive morbidity and mortality. Early childbearing also impedes the overall development of teenage girls and their access to education and labour force participation.

 

Critical indicators to comprehensively monitor adolescent birth rate would look at the median age at marriage, legal age at marriage and access to sex and sexuality education

5.3.1      Median age at marriage

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5.3.2 Legal age of marriage 

The legal age of marriage in Viet Nam is 18 for women and 20 for men.

In Vietnam, arranged marriage is not legally accepted as Article 9 of the Marriage and Family Law stipulates that ”the marriage is voluntarily decided by the man and the woman; neither partner is allowed to force or deceive the other; nobody is allowed to force or obstruct their marriage.”^[26] However, in reality, arranged marriages do happen between poor girls mostly from the south of Vietnam and men from Taiwan and Korea.

5.3.3 Sex and sexuality education

Sex education is defined as the basic education about reproductive processes, puberty and sexual behaviour. Sex education may include other information, for example about contraception, protection from sexually transmitted infections and parenthood.^[27] Sexuality education is defined as education about all matters relating to sexuality and its expression. Sexuality education covers the same topics as sex education but also includes issues such as relationships, attitudes towards sexuality, sexual roles, gender relations and the social pressures to be sexually active, and it provides information about SRH services. It may also include training in communication and decision-making skills.^[28] 

In Vietnam, from 1995-96 onwards, the Ministry of Education and Training decided to integrate education on HIV/AIDS prevention into the official curriculum of secondary schools throughout the whole country. This move consisted of incorporating lessons on reproductive health and HIV/AIDS.^[29] From 2002 to the present, after the issuance of the decision 40/2000/QH10 regarding school reformation, and with the support of UNFPA, the Population and RH curriculum in upper-secondary schools has been developed and is in the process of being piloted. It has been integrated into the school text books for Biology, Civics Education, Geography, Language and into extracurricular activities for  Grades 10 to 12 in some provinces. The final evaluation by UNFPA noted that most of the information on adolescent RH mainly focuses on pathological aspects of RH and contains poorly clarified/ confusing/wrong concepts and statements; information which is sometimes insufficient or even incorrect; the use of outdated statistics, and; poorly written Vietnamese. Yet the integration of adolescent RH in upper-secondary schools has shown increased knowledge among students. Rapid assessment confirmed that more than 60% of students in all schools are aware of basic adolescent RH issues such as STDs/HIV/AIDS, condoms, oral contraceptive pills and emergency contraception

5.3.4 Access to reproductive health services for adolescents within the public health system

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5.4 Contraceptive prevalence rate (Current contraceptive use among married women 15-49 yrs old any method%:

a.    2000: 74.2^[30]

b.    2005: 76.8^[31]

c.    2008: 79.5^[32]

 

Vietnam has a high CPR – 74.2 (2000), 76.8 (2005), 79.5 (2008).

 

Critical indicators to comprehensively monitor contraceptive prevalence rate would include looking at range of methods available including access to modern methods and provision of informed choice.

Beyond the numbers for CPR it is essential to look at access to a range of contraceptive services.

 

5.4.1 Range of contraceptive methods available.

The 2005 DHS shows that 48.02% of contraceptive users use IUDs. Vietnam also has a high proportion of traditional method users – 27.7% of all contraceptive users rely on traditional methods. Traditional methods generally have higher failure rates and hence lead to more unplanned pregnancies. If in Vietnam, the two main methods of contraception are IUDs and traditional methods, this leads to the question whether the range of contraceptive methods is actually available for women to choose the method most suited to them? Or whether despite a high CPR, women are not being empowered enough to exercise the control over their fertility that they so desire.

 

5.4.2 Provision of informed choice service provision. 

Informed choice of family planning methods is an important rights indicator. However it has not been commonly regarded as an important aspect of the service provided with the contraception method. Informed choice includes: information on the full range of methods including traditional and male methods; information on side-effects of all methods and the appropriate course of action; and information on the efficacy of each of the methods.^[33] 

Providers’ biases appear to affect the availability of information to users in Vietnam: “Providers’ biases in favour of IUDs were often evident, with other methods mentioned only if a client did not want to use an IUD. Many clients felt that they had not received sufficient information about contraception and were eager to ask questions to the assessment team members interviewing them.”^[34]  

Recent research in Vietnam also shows that low quality of family planning counselling and also post-abortion counselling has limited the choice of women and couples.^[35],[36]

 

 

5.5 Unmet Need for contraception:

 

a.    2000:

b.    2002: 4.8^[37]

c.    2005-8:

 

Unmet need is low in Vietnam at 4.8%.

Even then unmet need is higher for women living in the more remote areas in of the country: unmet need is “highest among women in the Central Highlands (12.3%). It is lowest among women in the Red River Delta (3%) and the Mekong River Delta (4%).”^[38] Unmet need is also highest among the youngest age group of women (15-19 years) in Vietnam. ^[39]

 

The accepted definition of “[u]nmet need for contraception is the percentage of fertile, married women of reproductive age who do not want to become pregnant and are not using contraception.”^[40] The concept of unmet need is an important one because it assesses the ‘need’ for contraception based on whether and when a woman wants a child or another one rather than focusing on government limits on family size. The limitation, currently, is that the DHS calculates unmet need based on a sample of married, heterosexual women and not single, unmarried women and this does not accurately capture the extent of unmet need in a country. Another limitation is that it assumes all users as having their need ‘met’ including women with infertility and secondary infertility. But many women may be using a contraceptive method not of their choice due to provider bias or government policy as earlier discussed and this constitutes an ‘unmet need’ too. It is also important to keep in mind that contraception is primarily focused on pregnancy prevention. There is also an urgent unmet need for disease/infection prevention which is not being considered.^[41]

 

Critical indicators to comprehensively monitor unmet need would take into account differences between total and wanted fertility rates and reasons for non-use of contraception.

5.5.1 Total and Wanted Fertility Rates

It is important to look at Wanted Fertility Rates and Total Fertility Rates to also establish unmet need.

a.    Total Fertility Rate (2005): 2.3^[42]

b.    Wanted Fertility Rate (2005)

c.    % difference

 

Data is not available in Vietnam for wanted fertility rates.^[43]

5.5.2 Reasons for non-use of contraception

One of the most common reasons given by married women with an unmet need for not using contraception is associated with the supply of methods and services and within this category, concerns about the side effects, health consequences and inconvenience of methods were the most prominent reasons. The prevalence of these concerns is particularly high in Southeast Asia.^[44] This is true in Vietnam.

 

5.6 Antenatal care coverage

a.    At least one visit (%):

Ø  2000: 68.3^[45]

Ø  2005:

Ø  2006: 90.8^[46]

b.    At least four visits(%):

Ø  2000:

Ø  2002: 29.3^[47]

Ø  2005-8: