Introduction
Despite evidence of effective interventions to promote safe motherhood, morbidity and mortality related to pregnancy and childbirth remain major challenges to health care planners and policy makers in low- and middle-income countries. The progress towards fulfilling the fifth UN Millennium Development Goal (MDG 5), to reduce maternal mortality by 2015 by three quarters from the level of 1990, is still far off the track in most countries of the world [
1]. Furthermore, countries that on a national level actually have succeeded in improving maternal health and reducing maternal mortality are still faced with big inequalities between different segments of the populations. Disadvantaged groups of women tend to have higher rates of both morbidity and mortality, and less access to safe, affordable and acceptable health care services enabling safe pregnancy and childbirth [
1,
2]. This “hidden” ill-health further adds to the challenge of reaching MDG 5, not only for an average but for all. Attempts have been made to reduce health inequalities between advantaged and disadvantaged populations, on global, national and sub-national levels, and ensure opportunities to all members of a society to achieve good health [
3]. Most health systems are, however, inequitable, benefiting the well-off more than the disadvantaged [
4] and under-utilization of health care services are typically greater where the need is biggest, in accordance with the
inverse care law[
5]. In 2009 the World Health Organization (WHO) concluded that there is still a need to better understand determinants of reproductive health in order to improve access to health services for disadvantaged groups [
6].
Maternal health in Vietnam
The proportion of people living below the poverty line in Vietnam has reduced significantly in the last decades. According to data from the Vietnam Household Living Standards Survey (VHLSS) 2006 one fifth of the population was living below the poverty line as defined by the General Statistics Office as a per capita expenditure of less than 2 559 850 VND per person and year [
7]. The rate of poverty reduction has however been lower among less affluent groups [
8] and ethnic minorities [
9], widening gaps between different segments of the population.
Following the economic transition in the 1980s Vietnam has seen a decline in maternal mortality ratio over the past decades, from an estimated 170 in 1990 [
10] to about 70 in 2009 [
11]. Data on maternal mortality should however be treated with caution as no reliable official registration systems exist for maternal deaths in Vietnam, and estimates have merely been done based on survey data collected though indirect methods, such as the
sisterhood method[
12]. This is reflected by great disparities between various estimations. Analyses of existing data do however indicate considerable inequities between social groups Vietnam. According to data from 2000/2001, ethnic minority groups had a maternal mortality ratio that was almost 4 times the size of that in the ethnic majority group [
12].
In 2009, UNICEF published a report on inequities in maternal and child health in Vietnam [
8]. This study revealed that, although maternal health has improved over time, inequalities still existed between disadvantaged and privileged groups. Factors, such as household wealth and commune effect, were identified as important social determinants of maternal health care utilization. More recent studies have found major disparities in antenatal care utilization between urban and rural areas in Vietnam [
13]. There is, however, still a need to better understand the relative importance of the different social determinants of health and potential synergy effects between them, in order to target resources efficiently and achieve MDG 5 in an equitable manner. The aim of the study is therefore to reassess available data on antenatal care coverage and skilled birth attendance in order to identify disadvantaged populations and better understand inequity in maternal health for all in Vietnam, with a special focus on ethnicity.
Results
Sample characteristics
A total of 9,473 women of reproductive age (15–49 years) were interviewed in the MICS 3 survey in Vietnam, with a response rate of 94%. The 1,023 interviewed women who had given birth to a live child two years preceding the survey were included. Of these women 78% (797/1,023) lived in rural areas, and 28% (284/1,023) in households classified as poor. Almost three quarters (71%) belonged to one of the two ethnic majority groups, Kinh and Chinese, and 87% had attended school. Only 7% were below the age of 20 years by the time of the interview.
Antenatal care coverage
Data on antenatal care had been successfully collected for 1,016 women. Analyses reveal that 87% (883/1016) had received antenatal care by skilled personnel at least once during their last completed pregnancy (Table
1). Controlling for living area, multivariate analyses show that education, wealth and ethnicity were all significantly associated with antenatal care coverage. The greatest discrepancy was found between ethnic groups, where the ethnic minority women had a more than threefold risk of not receiving antenatal care (OR 3.5, 95% CI 1.95–6.35) compared to women belongning to the ethnic majority group.
Table 1
Multivariate analysis of antenatal care coverage and selected structural determinants (adjusted for living area), percentage and adjusted odds ratio (OR), women age 15–49, MICS 3 Vietnam 2006 (n = 1,016)
Education
| | | |
Educated | 826 | 75 | Ref |
Uneducated | 57 | 58 | 2.78 (1.68-4.60)** |
Ethnicity
| | | |
Kinh/Chinese | 692 | 30 | Ref |
Other | 191 | 103 | 3.51 (1.95–6.35)** |
Wealth
| | | |
Non-poor | 700 | 34 | Ref |
Poor | 183 | 99 | 2.62 (1.46–4.67)* |
Stratified logistic regressions reveal an increased risk for ethnic minority women of not utilizing antenatal care, independent of economic status (Table
2). The odds ratio (OR) for poor ethnic minority women was 3.06 (95% CI 1.27–7.41) and 4.27 (95% CI 1.81–10.09) for non-poor ethnic minority women, compared to ethnic majority women of the same wealth status. Wealth was equally associated with the outcome independent of ethnicity. Women who belonged to an ethnic minority and were living in a poor household had an almost 10 folded risk (OR 9.69, 95% CI 5.15–18.24) of not receiving antenatal care, as compared to ethnic majority women living in a non-poor household.
Table 2
Multivariate analysis of antenatal care coverage and wealth stratified by ethnicity (adjusted for living area and education), women age 15–49, MICS 3 Vietnam 2006 (n = 1,016)
Kinh/Chinese | Non-poor | 639 | 23 | Ref | 0.31 (0.12–0.82)* | 0.23 (0.10–0.55)** |
| Poor | 53 | 7 | 3.21 (1.22–8.41)* | Ref | 0.76 (0.27–2.17) |
Other | Non-poor | 61 | 11 | 4.27 (1.81–10.09)** | 1.32 (0.46–3.76) | Ref |
| Poor | 130 | 92 | 9.69 (5.15–18.24)** | 3.06 (1.27–7.41)* | 2.37 (1.13–4.96)* |
When stratifying the education variable by ethnicity it was found that being uneducated was associated with an increased risk of not receiving antenatal care in the ethnic minority group, with an OR of 2.95 (95% CI 1.70–5.12). No such relation could be established within the ethnic majority group. For educated women, belonging to the ethnic minority group was found to be a risk factor, but not for uneducated women. The OR of not receiving antenatal care was 3.30 (95% CI 1.72–6.35) for educated ethnic minority women as compared to educated ethnic majority women.
Skilled birth attendance
Out of the 1,023 women of reproductive age with a live birth during the last two years, data on birth attendance had been recorded for 1,021. In 2006, 82% of the women had been attended by skilled personnel (Table
3). Multivariate analyses of determinants show that education, wealth, and ethnicity were all significantly associated with skilled birth attendance. After controlling for significant intermediary and structural determinants, the greatest discrepancy was found between ethnic groups, where the risk of not receiving skilled birth attendance was almost 7 times higher (OR 6.85, 95% CI 4.01–11.7) in the ethnic minority group, as compared to the Kinh/Chinese group.
Table 3
Multivariate analysis of skilled birth attendance and selected structural determinants (adjusted for age and living area), percentage and adjusted odds ratios (OR), women age 15–49 years, MICS 3 Vietnam 2006 (n = 1,021)
Education
| | | |
Educated | 799 | 106 | Ref |
Uneducated | 33 | 83 | 3.52 (2.07–6.00)** |
Ethnicity
| | | |
Kinh/Chinese | 695 | 31 | Ref |
Other | 137 | 158 | 6.85 (4.01–11.7)** |
Wealth
| | | |
Non-poor | 698 | 41 | Ref |
Poor | 134 | 148 | 3.20 (1.91–5.38)** |
In a stratified analysis, ethnicity was found to be associated with skilled birth attendance, independently of wealth status (Table
4). Poor women in the ethnic minority group ran a 6.27 (95% CI 2.37–16.6) times greater risk of not being attended by skilled personnel as compared to poor women in the ethnic majority group. An even greater disparity was found when comparing non-poor women in the different ethnic groupings, where ethnic minority women had an OR of 7.67 (95% CI 3.54–16.6) of not receiving skilled attendance at birth. At greatest risk of not receiving skilled birth attendance was poor women from ethnic minority groups who had an OR of 25.5 (95% CI 11.4–56.8), compared to non-poor Kinh/Chinese women.
Table 4
Multivariate analysis of skilled birth attendance and wealth stratified by ethnicity (adjusted for living area, age and education), women age 15–49, MICS 3 Vietnam 2006 (n = 1,021)
Kinh/Chinese | Non-poor | 645 | 21 | Ref | 0.15 (0.06–0.43)** | 0.13 (0.06–0.28)** |
| Poor | 50 | 10 | 6.41 (2.29–18.0)** | Ref | 0.63 (0.23–1.70) |
Other | Non-poor | 53 | 20 | 7.67 (3.54–16.6)** | 1.58 (0.59–4.26) | Ref |
| Poor | 84 | 138 | 25.5 (11.4–56.8)** | 6.27 (2.37–16.6)** | 2.91 (1.42–5.99)* |
Ethnicity was further found to be a significant determinant among educated women, who ran a six folded risk (OR 6.33, 95% CI 3.33–12.0) of giving birth without skilled attendance if they belong to an ethnic minority group, as compared to educated women in the ethnic majority group. Due to small sample size, no similar associations could be established among uneducated women.
The effects of ethnicity
The Total Causal Effect (TCE) describes the sum of all possible pathways in the DAG (Figure
2), whereas the Natural Direct Effect (NDE) describes all pathways not going through household economic status (Table
5). Thus, through g-computation we found that a major part of the effect of ethnic status on the outcome variables was mediated through household economic status. However, 25% (NDE 0.0312805/TCE 0.1231672) of the causal effect of ethnicity on skilled birth attendance and 18% (NDE 0.0156403/TCE 0.086999) on antenatal care attendance were not due to poverty (Table
5).
Table 5
G-computation based on causal diagram calculating the Total Causal Effect (TCE), Natural Direct Effect (NDE) and Natural Indirect Effect (NIE) of ethnicity on antenatal care and skilled birth attendance based on MICS3 data, Vietnam 2006
| G-computation estimate | Bootstrap Std. Error | Z | P > |z| | Normal-based (95% CI) | |
TCE | 0.086999 | 0.0152105 | 5.72 | <0.001 | 0.057187 | 0.116811 |
NDE | 0.0156403 | 0.0113028 | 1.38 | 0.166 | −0.0065129 | 0.0377934 |
NIE | 0.0713587 | 0.0153506 | 4.65 | <0.001 | 0.0412821 | 0.1014454 |
Skilled birth attendance
| | | | | | |
| G-computation estimate | Bootstrap Std. Error | Z | P > |z| | Normal-based (95% CI) | |
TCE | 0.1231672 | 0.01671 | 7.37 | <0.001 | 0.0904162 | 0.1559181 |
NDE | 0.0312805 | 0.0129089 | 2.42 | 0.015 | 0.0059796 | 0.0565815 |
NIE | 0.0918866 | 0.0124791 | 2.11 | 0.034 | 0.0019344 | 0.0508516 |
Discussion
In this study we have analyzed associations between antenatal care and skilled birth attendants, and different structural determinants of health. We have also tried to capture the causal effect of ethnicity on the outcome variables through novel statistical methods. Findings show that maternal health care utilization was still, in 2006, highly inequitable in Vietnam, determined by ethnicity, education, and wealth. The biggest inequities detected in this study were related to skilled birth attendance. While practically all Kinh/Chinese women had skilled attended deliveries, less than half of ethnic minority women had the same. These findings correspond to the results of previous analysis made on national survey data from 2001–2002 [
23].
The results demonstrate that ethnicity is an important social determinant for maternal health care utilization in Vietnam, and that ethnic minority women form a clearly disadvantaged group. Ethnic minorities tend to reside in rural areas and poor households, as well as have low education [
9,
24]. Physical distances to health facilities as well as lack of transportation and means to accommodate women and their family members, are factors previously identified as explaining the lower rates of maternal health care utilization in areas inhabited mainly by ethnic minority groups [
25,
26]. Studies have shown that as many as half of all women in remote and mountainous areas in Vietnam deliver their babies at home [
27]. Shortage of equipment, drugs and staff in the health facilities [
28], and indirect costs associated with seeking care are other factors of importance [
25]. Previous research reveals a relationship between use and quality of antenatal care and giving birth in health facilities [
29].
In an analysis of ethnicity and social development in Vietnam published by the World Bank in 2009, the reasons for ethnic minority groups being disadvantaged are suggested to be multiple and interacting. The findings can be summarized as ethnic minorities having fewer physical assets, as well as social assets (such as education and access to services), residing in remote areas, and not benefitting from government poverty reduction programs. Added to this may be other socio-cultural factors excluding them from economic development [
9]. The results indicate that as much as a quarter of the causal effect of ethnicity on lack of skilled birth attendance is mediated through other factors than being an effect of poverty. The use of statistical methods like G-computation allows us to look at the data from different angles and a better understanding is achieved through the use of various statistical methods complementing each other. The results of the G-computation verifies the results from the logistic regression models that ethnicity is not solely a matter of economy. At the same time it also reinforces the fact that ethnic minorities are marginalized and impoverished, showing that large improvements could be made in the provision of maternal health services if poverty among these groups was alleviated.
This study shows that the factors above cannot solely explain the health inequities observed between ethnic groups. Belonging to en ethnic minority is a risk factor in itself working in synergy with other factors. Although we can expect an overlapping effect between the structural determinants analyzed, those most at risk of not utilizing maternal health care are women of ethnic minorities who lack education and live in poor households.
Several studies, mainly of qualitative design, have made attempts to explain why ethnic minority groups are disadvantaged in terms of health care in Vietnam. Among barriers identified for utilizing health care services are traditional practices such as home deliveries [
24‐
26,
30] and complex rituals surrounding births [
24]. Perceived negative attitudes from health care personnel, language barriers [
24] and feelings of disempowerment and voiceless [
9] are also mentioned. Several studies have found gender sensitivity to be of particular importance to some ethnic minority groups, as many women do not feel comfortable being cared for by male personnel [
24‐
26].
It should be stressed that ethnic minority women in Vietnam make up a highly heterogenic group, of various ethnicities with differences in culture, language, place of residence, economic status and education levels [
9]. To fully understand these differences and their relation to the social determinants of maternal health care utilization is of outermost importance for targeting scarce resources efficiently. Empowering ethnic minority groups and involving them in the planning and implementation of interventions through open dialogues have shown to be successful elsewhere [
31‐
33].
The fact that the data used in this study was collected in 2006 is of concern. One can assume that much has happened since and that conclusions drawn from these data may be outdated. Collecting information through recall of reproductive history generates data that is even older than the date of collection, and may also be associated with a risk of recall bias. The broad patterns of social determinants of health care utilization are however likely to remain, which is supported by findings made by Boerma et al. in 2008. Analyzing survey data from 54 countries on maternal and newborn health interventions, they found that patterns of inequity tend to be consistent over time [
34].
To fully grasp the current situation for disadvantaged groups in Vietnam updated data is however of essence and the collection of reliable information on incidence and causes of maternal mortality, through strengthening of civil registration systems, will be of vital importance to enable promotion of maternal health and survival.
Concluding remarks and recommendations
According to findings made in this study, ethnic minority women constitute a disadvantaged group in Vietnam. The fact that they tend to reside in rural areas, lack education and live in poor households only partly explains their increased risk of not receiving vital maternal health care. This study shows that belonging to an ethnic minority group is a risk in itself. The complex interactions and synergy effects between different social determinants of health highlighted in this study stresses the importance of parallel investments in other sectors than health care, such as education, income generating activities, women empowerment, and infrastructure, in order to promote safe motherhood.
Competing interests
The authors declare no competing interest in relation to the article.