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Paper for the conference "Expanding Access: Advancing the Roles of Midlevel Providers in Menstrual Regulation and Elective Abortion Care"
South Africa 2 - 6 December 2001.
Paper for the conference "Expanding Access: Advancing the Roles of Midlevel Providers in Menstrual Regulation and Elective Abortion Care" South Africa 2 - 6 December 2001.
The paper in pdf-format
Vietnam Abortion Situations Country Report
Vietnam Abortion Situations
Dang Thi Nghia
Table of contents
Section 2. Midwives’ role in abortion services
Section 3. Lessons learned
Section 4. Questions and concerns
Section 1. Country profile on abortion services
The Socialist Republic of Vietnam is located in South East Asia. Vietnam is the second most populous nation in Southeast Asia after Indonesia and the thirteenth most populous in the world. At the first census after reunion in 1979, the population of Vietnam was 52.7 million. After ten years, the population increased to 64.4 million in 1989 (Census 1989). The population was 77.7 million in 2000 (MOH, 2000). The speed of population growth will have a seriously effect on the socioeconomic development of the country, a concern which has led the government to carry out a family planning programs in order to reduce the population growth rate.
The young dependency ratio in Vietnam was high at 42.5 per cent in 1989. It was estimated that between 500.000 and 600.000 women would enter the reproductive period every year for a long time in the future, producing a high momentum of population growth.
According to the Health Statistics Yearbook of the year 2000, the infant mortality rate is 36.7 per thousand live births, the maternal mortality rate is 95 per 100,000 live births. Life expectancy at birth is 67.8 years. All of which indicate that there is a better health care in Vietnam compared to other countries of the same income level (World Bank. 1992.).
Most Vietnamese, approximately 80 per cent of the population live in rural areas. According to the 1989 census, Vietnam had six cities where 13.6 per cent of the urban population lived.
Although, Vietnam is a low-income country, the literacy level of its population is high compared to the other developing countries of the region. Ninety six per cent of males and 84 per cent of females are literate and the average number of years of schooling for the total of population is 9.5 years. However the overall educational attainment is still low, only 1.6 per cent were graduated from university and it was different among the regions, namely the urban and the rural areas and the North and the South (1989 Census).
Women occupy 52 per cent of the jobs in the national economic sectors. Notably Vietnamese women have played an important role in the nation’s history and economy. In addition, compared with other developing countries in the region. Vietnamese women have high status. Despite the high status, the traditional society and the hierarchical and patriarchal family institutions exert a strong pressure on women’s thinking in the traditional culture.
A network of health services is well developed in Vietnam as a result of a strong commitment of the socialist policies. Commune Health Centers (CHC) were established at each commune of the whole country with almost 100 percent coverage. This is the basic level of health care services in which there is a staff in charge of pediatrics and gynecology/obstetrics, who is expected to implement the national programs on health such as maternal and child care and family planning services at the community level.
Information from MOH shows that in 2000 there were 51 per cent of the commune health centers
were headed by a doctor and the remaining are equipped with assistant doctors.
In 1989, the Council of Ministers promulgated a new decree liberalizing the operation of the health sector, allowing health workers to engage in private practice. The privatization of the health sector reduced temporarily the burden of health care on the Ministry of Health (World Bank, 1992). This also reduced the responsibility of the Ministry for reporting and recording with the result that the records of health services as well as of induced abortion became inadequate. Undoubtedly, abortions have tended to go under reported and are performed in less hygienic conditions (Quoc Anh et al,1997).
1. Summary of reproductive health and abortion statistics
Table 1.1 Vietnam basic reproductive health indicators
Table 1.2. Number of Abortion
Abortion Ratio is the number of abortion per 100 live births.Source: Health Statistics Yearbook in 1994, 1995, 1996, 1997, 1998, 1999, and 2000.
The estimated percentage of all abortions by MVA Single valve (before 6 weeks) is 60% of total abortion compared to 40% from 7 to 12 week and late abortions after 12thweek (Hieu, 1997).
Table 1.3. Percentage of currently married women who had ever had induced abortion and abortion during 1994 and 1997
Source: Nguyen Quoc Anh et al, 1997
Table 1.4. Percentage of ever married women who sought induced abortion by religion
Sourse: Nguyen Quoc Anh et al , 1997
Roughly, 600.000 to 800.000 Vietnamese women undergo abortions every year. This estimate includes a large number of repeat abortions. Excluded, however, are those abortions performed in private medical clinics. Counseling and provision of information on contraception is still limited. This is the main reason for the high number of unwanted pregnancies. Post-abortion counseling is inadequate, resulting in repeat abortions (WHO, 1999)
2. Laws and policies
Abortion is provided to both single and married women. In the past menstrual regulation was performed routinely without conducting a pregnancy test. Since 1995, The Ministry of Health requested pregnancy test to be conducted prior to all menstrual regulations.
In order to increase access to family planning services in general and abortion care in particular, MOH issued the Decision number 220/QD-BYT on February 22, 1993 and lately the Decision number 385/QD-BYT issued on February 13, 2001 clearly defined tasks for each level’s of health care in the field of reproductive health including abortion services. According to the Decision, midlevel providers are allowed to perform abortion services at commune health centers.
Until recently, early abortions-prior to 6 weeks was performed with manual vacuum aspiration (MVA) and abortions from 7-12 weeks were performed by dilation and curettage (D&C). From 1998, MCH/FP Dept. MOH recommended the use of vacuum aspiration for all first-trimester abortions. Both contraception and abortion services are widely available as an integrated part of the basic health care services provided by public health sectors. And trained midlevel providers are permitted to perform MVA.
Some policies which subsidized for abortion (drugs and procedure cost subsidize for women who failed in using contraceptive methods). Another policy provides incentive for health workers who perform the service. Those policies may lead to increase number of abortion. It also needs to consider about the cost of abortion service. Increase the cost of abortion will contribute to enhance the qualification of abortion procedure because health facility will have more money to invest in equipment, providers will have more incentive. This will help to reduce morbidity and mortality of mothers.
At the moment the cost for an abortion is low even lower than the cost of a contraceptive method such as pill or condom, therefore many women use abortion as complement to contraceptive methods when they have complications (WHO, 1999). On the other hand, high cost of abortion may reduce access to health care by group of low-income women. The cost for MR in public sector is around 1 to 2 USD. However, it is free for women who failed in using modern contraceptive methods. This cost in private sectors varies a lot from 5 to 20 USD, depending on the location of the clinic and the provider’s qualification.
3. Provider profile
At Secondary Medical School, students both midwifery and nursing have to complete 3 years education. In the past, secondary medical schools also trained assistant doctors. This kind of training lasted also 3 years.
There is no formal curriculum for abortion training both clinical and counseling. After graduation from schools, Health care providers have to pass at least two months training courses on abortion care and then they are certified to provide abortion services.
Providers of reproductive health services
Table 3.1 Providers of abortion services
4. Organization of abortion care|
a. Abortion services
Midwives working in primary health care (Commune Health Center) are responsible for a wide range of reproductive health services, including antenatal and postpartum care, contraceptive services, abortion services including technical procedure as well as counseling, and normal deliveries. Counseling service is not well implemented by this group of providers.
In all these activities midwives are working independently if there is no Ob/Gyn specialist in the site. Likewise midwives at maternity hospitals attend normal deliveries, while the obstetricians take care of complicated cases. Midwife who works in an Ob/Gyn hospital or in an Ob/Gyn wards of a general hospital is working under the supervision of Ob/Gyn doctors.
The table below describes organization of abortion care as defined by Decision number 385/QD-BYT issued by MOH:
Table 4.1. The Organization of abortion care
According to the decision physicians and midlevel providers who accomplished abortion training are allowed to perform abortion. Actually in many public health facilities where Ob/Gyn doctors are available, registered nurses or nurse-midwives or assistant doctors are only assisting the doctor in the care of surgical abortion, and treatment of complications or evacuation of incomplete abortion.
b. Systematic records keep
Table 4.2. Availability of abortion service delivery records
The validity of the records: The validity of the records is rather questionable (JOICEF, 2000). Numbers of pregnancy termination are collected only from public health care sectors. It is easy to understand that there are quite a lot of missing numbers of abortion from private sectors.
c. Referral plan
In urban areas: Since the district and MCH/FP centers or provincial hospitals are normally close to urban area therefore women in these areas can go directly to this level to get abortion services.d. The differences between private and public sectors
Since 1989 private health sectors have been allowed to perform MR with the permission from MOH. According to the decision number 15/1999/TT-BYT of MOH, private sectors are only allowed to performed MR (for less than 6 weeks of gestation) by a trained health care provider who has the permission from MOH to do this service. Recently, abortion services provided by haft-private health care providers are common. Those providers are working at public hospitals (especially in provincial and district hospital) and they also have their own clinics at home. Numbers of private health staff who are providing abortion service are not well documented (WHO, 1999).
Regarding the quality of services provided by private sectors, women who has money are more likely to get the service from private sectors. According to them there are several benefit of seeking private service: (1) more convenience in term of time (no waiting time), (2) more method of pain management (3) more privacy. (WHO, 1999). On the other hand, reports from local health authorities also indicate that they are often in substandard conditions in term of counseling and infection prevention as well as not properly trained.
e. Integration with other service
At health care facility including both private and public sectors, doctors, midwife and assistant doctors who are working for reproductive health services provide both abortion service and other sexual and reproductive health services such as family planning service and counseling, provide Ob/gyn examination and treatment.f. Policy on young, adolescent people
Regarding MOH regulations, adolescent under 18 year old is requested to have permission or consent from parents in order to seek abortion at the second trimester. They can have the first trimester abortion without consent from their parents or husband.
5. Knowledge and perception of abortion services
Pregnancy termination were considered to be a sin in traditional Vietnamese society but has become more widely accepted among younger women in recent times (Johansson et al., 1996). Many women, however, continue to make a moral differentiation between early menstrual regulation when the fetus is not yet formed and considered to be a "blood clot" or a "been seed", and later abortion which destroy a fetus.
Thus, many women attempt to go for a menstrual regulation as early as possible when they considered themselves to be pregnant. Whether the abortion is early or late, many women consider that it is better to have an abortion than to have a child for which family resource are inadequate to proper care (Gammeltoft, 1996).
Abortion services are now available and the services are well known in both rural and urban areas. Women know where to go for this kind of service.Section 2. Midlevel providers and abortion services
1. Description of Midlevel Providers:
According to existing data from the year 2000 from Personnel Department, the Ministry of Health, there were 9,362 commune health centers (CHC) which have midlevel providers (including trained midwives and assistant doctors). This represents 89 % of the total of 10,505 CHC in Vietnam. The numbers of midlevel providers are different among areas. Over the country there were 38% (23/61) provinces that have 100% CHC covered by midlevel providers. The table below describes the number of CHC which are covered by midlevel providers.
Table 2.1. Numbers of midlevel providers by regions
Source: MOH, 2000
Vietnam history has undergone many difficulties. Passed two long and hard wars, it seems dried almost human and property. During the wartime, men, youth were encouraged to go to battles. Remaining was old person, middle-age women, teenagers and children. Middle-age women and teenagers had to carry out most of work that men did before.
Both sides, battle and behind battle needed health care staff therefore short nursing training courses were opened. These courses lasted 9 months, 12 months, or 18 months depended on requirement. Midwives are the same duration with training for nurses. In the past, courses for assistant doctors were also established to fill the need for health care. Finishing this course, students became Ob/gyn and child-care assistant doctors. This training has been stopped in many secondary medical schools but many assistant doctors are still working in health care services over the country.
Since 1960s, midwives, ob/gyn assistant doctors have been permitted by law to perform abortion. However, Midlevel providers are facing difficulties such as insufficient knowledge (working long time without retraining/refresh training), inadequate or old equipment, insufficient counseling skills.
3. Scope of abortion practice of midlevel providers
Table 3.1. Scope of abortion practice of midlevel providers
4. Incentives and barriers to midlevel provision of abortion services
In some cases, especially at commune health centers, health staff have been trained to provide abortion services. However, they can not perform the service at their clinics because the health facility does not meet the requirement to perform the service.
5. Professional Organization for midlevel providers
(VAM) is a young and dynamic organization. Since 1995, the organization has grown to 3,000 members in the whole country. VAM has an approved constitution and VAM is close to completing formalities to be accepted as a member of the International Confederation of midwives. VAM is ready to take its place in the international community of midwives.6. Advocating abortion services provision by midlevel providers
The role of midlevel providers in providing abortion services are advocated by law, accepted by clients and supported by policy makers. In order to maintain these factors, midlevel providers have to learn and practice continuously, to increase knowledge, improve skills. However, knowledge and practice skills are not enough, they should know how to do counseling properly.
Section 3. Lessons learned related to access to safe abortion services
However, there are also some factors which limit access to safe abortion care:
Section 4. Questions and concerns regarding midlevel provision of abortion services
Updated 19 June 2002