Midwifery in Vietnam: A Closer Look at Serving Ethnic Minority Communities
In the past three decades, Vietnam has seen significant improvements in maternal and child health. In 2008 the country’s poverty rate fell to 15% from 58% in 1993, and the infant mortality rate (IMR) fell from 44 to 12 deaths per 1,000 live births between 1990 to 2011, while the maternal mortality rate (MMR) fell from 233 to 56 deaths per 100,000 live births between 1990 and 2011.
The country is acknowledged by the WHO as on track for achieving their Millenium Development Goals, likely partially due to a strong commitment to universal health coverage. Unfortunately though, out-of-pocket payments still comprised 50% of total healthcare expenditures between 2000 and 2010, indicating that work still needs to be done. Vietnam’s previously majority public sector of healthcare transitioned to a market-oriented privatized health economy in 1986, which has resulted in public hospital fees and legalized private practices. This privatization has pushed a more modernized agenda of technologization as well (Vietnam’s cesarean-section rate is one of the highest in Asia, at 36%), making pregnancy and birth into a medical condition requiring technical support. However, for people unable to afford care in this privatized system, birth in a facility has become less accessible.
Nonetheless, despite the trend of medicalization in the past thirty years, healthcare providers often collaborate well together. For example, one article states that “It is well known that nurses, midwives, and pharmacists do not work separately but in conjunction with doctors,” indicating that the work of midwives is well-respected. Vietnam currently has approximately 35,162 midwives (including nurse-midwives) as well as 1,801 other health professionals and 101,508 community health workers with some midwifery training, although there are only 5,000 obstetricians in the nation. Access to midwives, for this reason, is easier than access to other health workers, both financially and geographically. Furthermore, density data for midwives have shown that midwives significantly improve mortality rates:
“It is estimated that, while holding other variables fixed, on average if there are 10 doctors more and 10 nurses more per 10 000 population, the IMR decreases, respectively, by 4.4% (i.e., 44 deaths less per 1 million live births) and 1% (10 deaths less per 1 million live births). Meanwhile, this effect is much bigger for midwives and pharmacists, at 9% (90 deaths per 1 million live births) and 19% (190 deaths per 1 million live births), respectively.”
As of 2008, 72 midwifery education institutions exist in Vietnam, with a new three-year direct-entry program recently created. Licensing is now required for all health professionals. While these midwifery programs are accredited, there is no legislation existing that recognizes midwifery as an autonomous profession, and midwives hold no protected title.
This, in some ways, represents Vietnam’s history of midwifery; these educational institutions and accreditations are relatively new. Maternal care historically came from traditional birth attendants (TBAs), women trained by family members for generations, without any formal certificates. Thus, midwives as we know them today have not always existed in Vietnam, though their basic skills have been practiced for centuries.
Today, midwives generally work most typically in Commune Health Stations (CHS), which serve as the primary access points for patients prior to the district, provincial, or national level of healthcare. At CHSs, midwives provide antenatal and postnatal care, attend to delivery, provide gynecological examination and treatment, as well as family planning services such as IUDs, oral contraceptives, and condoms.
Although this model seems to be improving maternal healthcare indicators, deep disparities exist between ethnic minority households and Kinh/Hoa (majority ethnicity) households. Mostly inhabiting rural, mountainous regions, women of ethnic minority are three times more likely not to access prenatal care and are six times more likely not to deliver with a skilled birth attendant. These disparities are increasing over time, as seen in the fact that not having a health facility birth rose from 5 times to over 20 times higher than for women of majority ethnicity between 2006 and 2011.
This is even more so compounded for women of ethnic minority in rural regions; though IMR and MMR values have been shown to be 4 times higher for non-Kinh groups, some studies have shown that the IMR and MMR of women in the northern mountainous regions of Vietnam are approximately 10 times higher than the national average. While cost of healthcare is not an excessive barrier due to the nationwide Health Care Fund for the Poor, which offers free healthcare through the CHC, countless other barriers hindering accessibility exist. For example, one study unfolds that barriers to care-seeking include limited insight into health knowledge, lack of decision-making power, reliance on traditional medicines, traveling difficulties, distrust of care, difficult geography or terrain, and incongruent language, for example.
Additionally, relations between Vietnamese government and ethnic minorities is not strong. Governmental policy has previously referred to these groups as underdeveloped and backwards, and attention to local CHSs is only given once they pass government inspections, at which point damage has already been done. To mitigate these issues and address high IMR and MMR, the National Targeted Programme on Safe Motherhood instated the training of young local ethnic midwives to work as village midwives, known as ethnic minority midwives (EMMs). Two years after this, in 2013, the Ministry of Health (MoH) officially recognized EMMs as village health workers by granting them monthly salaries and establishing a 6-month training program to ensure consistency. Although this training is different than more formalized midwifery training, EMMs are meant to address the shortage of human resources while being able to share language, culture, values, and beliefs of the local women they engage with, building trust within the community.
These EMMs are chosen to work within their own villages to ensure that they can best communicate with the local women to meet language, culture, and accessibility needs. For this reason, the MoH does not assign healthcare workers to specific regions. In addition to the 6-month training program previously mentioned, these EMMs have often priorly been trained as village health workers or through other EMMs, although most of them have not graduated from high school and have at most finished fifth or sixth grade.
EMM training consists of learning about prenatal care and counseling, home delivery, postnatal care and counseling, home visits following delivery, neonatal counseling, and referral to higher-level healthcare facilities should there be complications. More than anything though, because EMMs are expected to encourage women to deliver in health facilities, they are viewed by public health professionals as mediators between traditional culture and the health system.
Although they do engage with a few traditional health practices, these EMMs typically follow a more medical preventative approach and focus on risk minimization while using their positions as insiders to these communities to communicate efficiently by eliminating the language barrier. This fosters a sense of trust between the healthcare provider and patient, allowing them to build a lasting relationship that ultimately leads to more positive health outcomes. Nonetheless, these EMMs are not completely independent — they are required to report their work to a midwife once a month during meetings at the CHSs. However, many EMMs report that they are grateful for this collaboration and support, and even express a want for more training.
EMMs state that much of their motivation to work stems from their relationships with their home community and strong interpersonal bonds; they want to help the women in their own regions. Additionally, Vietnamese expectation that social and cultural capital is more important than economic capital fuels these interactions. However, distrust from clients, perception of poor work achievements, inability to provide quality services, large work loads, and little supervision have been marked as demotivating factors.
Although the utilization of EMMs differs slightly among regions, studies have shown that EMMs typically provided more prenatal and postnatal care as compared to delivery services, matching the job description. Prenatal care was shown to be utilized less than postnatal care: 33.4% had prenatal checkups, 57.3% and postnatal checkups, and 20.1% were attended during home deliveries. However, 24% of ethnic minority women had never heard about EMMs and only 45.6% of women who had heard about them used their services, indicating that more information has to be spread regarding their presence. Interestingly, the use of EMM services was higher among mothers aware that the EMMs had been trained (62.7%), those who believed many people in the village knew about EMMs (67.5%), and those who knew about EMMs from a healthcare worker (three times more likely). Additionally, it was noted that mothers, husbands, relatives, and friends were the most common source of information about EMMs.
All this data indicates that utilization of EMMs’ care may be improved if training is established, and if information about their services is circulated by health workers and to people other than pregnant mothers. Despite these relatively low percentages of utilization of EMMs, 74.2% of mothers aware of their services reported that they would feel comfortable calling an EMM for help whenever they needed it, displaying that although their existence may not be well-known, those who do know about them are appreciative to have their needs met.
The Hmong people, for example, greatly benefit from the services of the EMMs. Known to be the least assimilated, most impoverished ethnic group living in the mountainous regions of northern Vietnam, the Hmong people make up only 1% of the total Vietnamese population and face incredible health disparities and discrimination. Many of their traditional customs — as described in Donn Hart’s, Anuman Rajadhon’s, and Richard Coughlin’s book Southeast Asian Birth Customs — may pose constraints to maternal healthcare.
For example, rituals performed at home considering the Hmong family house as an ancestral and spiritual site prevent institutional deliveries, and customs that prohibit strangers from entering houses may complicate the work of healthcare officials. Birthing women typically remain clothed and deliver in a squatting position, while fathers are responsible for ritual activities including burying the placenta and cutting the umbilical cord — activities that would often be prohibited with healthcare workers who do not understand their cultural significance. EMMs are invaluable in cases like these, providing quality care with cultural competency that matches each family’s needs due to their own innate experience and understanding.
Unfortunately, these EMMs are often seen as a temporary fix until more formal medicalization and institutionalization of birth can be reached. However, these women’s ability to directly address local needs and share language by being embedded in the communities they are serving is essential, allowing maternal healthcare services to reach populations of people otherwise underserved. Similar programs have been shown to work in the Upper East Region of Ghana, Indonesia, China, and Tibet, and could possibly be extended to other regions that experience health disparities for similar reasons. By extending trust and sharing commonality with their patients, these EMMs can greatly bridge the human resource gap and serve these pregnant women with the quality care they need.
To put a face to these women and truly understand the importance of the work they are doing, take a look at this fantastic documentary following the work of one EMM working with the Hmong community!
