ABSTRACT
Introduction: Few quantitative studies globally have evaluated determinants for home, health centre and hospital birth separately, despite large differences between the services provided.
This study explores the sociodemographic and pregnancy-related determinants of birth- setting in Vietnam (n=1812) for vaginal birth using Young Lives data. Methods: Random sampling obtained 2,000 children (age 6-18 months) within four purposively selected regions: Northern Uplands, Red River Delta, Central Coast and Mekong Delta. Multinomial regression modelling explored determinants of use across birth setting: home (reference), health centre and hospital. Results: Women in the study reported hospital delivery (n=813, 45%), followed by health centre (n=563, 31%) and home (n=436, 24%). Women delivering
at home were predominately from rural areas (98%), among the poorest women (73%), had no antenatal care (53%) and were multipara (64%). Women who lived in a rural area had lower odds (OR=0.29; 95% CIs 0.13-0.66) of health centre delivery, compared to their urban counterparts, however this was not the case for hospital delivery. Lower wealth decreased the likelihood of hospital delivery (OR=0.46;
95% CI 0.28–0.74), compared to home birth but had no signifi cant effect on health centre delivery. Conclusion: This study found that sociodemographic and pregnancy-related determinants for home birth, health centre and hospital delivery were different for a number of factors in this population, having important implications for policy development.
Keywords: home birth; Young Lives; Vietnam;
maternal healthcare; inequity
DETERMINANTS OF HOME, COMMUNE
HEALTH CENTRE AND HOSPITAL SETTING FOR VAGINAL BIRTH IN VIETNAMESE WOMEN
Tina Lavin1*, Elizabeth A Newnham2,3, David B Preen1
1 Centre for Health Services Research, School of Population Health, The University of Western Australia 2 School of Psychology, The University of Western Australia
3 FXB Center for Health and Human Rights, Harvard School of Public Health
* Corresponding author: Tina Lavin, Centre for Health Services Research, School of Population Health, The University of Western
INTRODUCTION
The United Nations Millennium Development Goal fi ve (MDG5), set in 2000, targets improved maternal health as a key indicator of national development and global health1. Worldwide, progress on this goal has reduced maternal mortality ratio (MMR) from 320 to 210 per 100,000 live births between 1990 and 20132. Vietnam has made substantial progress towards the target with a 2013 MMR of 49 per 100,000 live births reduced from 140 per 100,000 in 1990. Yet despite this reduction, the rate is still more than 30% above the 2015 target proposed by the United Nations of 35 per 100,000 live births2.
While there are numerous risk factors for poor maternal and newborn health during the intrapartum period1, evidence suggests that skilled birth attendance (birth with an adequately trained professional present and in an enabling environment) can reduce maternal and neonatal mortality and improve health outcomes3. Vietnam has focused on reducing disparities in reproductive health through the National Strategy for Reproductive Health Care 2001–20104. The strategy promotes equity of access between regions and population groups, through universal access to low cost, community-based, quality health services. This approach has resulted in considerable progress increasing birth with skilled birth attendants from 68.6% in 2000 to 92.1% in 20115.
Despite improvements in the coverage of skilled birth attendance, there remains sociodemographic inequity in maternal healthcare utilisation5. Women living rurally, those from poorer households and from ethnic minorities have poorer access to maternity health services6, despite greater need7, resulting
in greater morbidity and mortality6. Vietnam continues to address disparities in maternal health service use through the population and reproductive health strategy for 2011–2020 targeting universal coverage for reproductive health8.
In low-and-middle-income countries, non- institutional delivery or absence of skilled birth attendance has been associated with a range of factors including maternal age, parental education level, socioeconomic status, birth order, absence of antenatal care (ANC), availability of delivery services, and distance to health facility9-11. While some studies from selected provinces in Vietnam have investigated institutional delivery (delivery at any health facility)12,13 or birth with skilled attendants6, differences in health service type, such as commune health centre or hospital have not been explored. This is particularly important in Vietnam as there is a commune health centre in every commune but hospital delivery is only available at the district level. In addition, there is a paucity of quantitative work globally, on large representative samples that have evaluated individual and community determinants across a range of sociodemographic and pregnancy factors for health centre and hospital delivery, separately.
We used data from the on-going Young Lives prospective cohort study established in 2001 to explore sociodemographic and pregnancy- related determinants for women delivering at a home, health centre or hospital in Vietnam.
It is hypothesised that the determinants for health centre delivery are different to those for hospital delivery and additionally that women living rurally, with lower household education, from ethnic minority groups, with higher
parity, lower wealth index, and lower antenatal care will be less likely to seek health centre or hospital delivery and more likely to deliver at home.
Birth Setting
Reproductive health services are available at four levels in Vietnam: the national level (national referral hospitals), provincial level (provincial hospitals), district level (district health centres and district hospitals) and commune level (commune health centres).
Under the national population programme, commune health centres are responsible for registering and managing all pregnant women in the commune. Almost every commune health centre has at least one midwife who is responsible for antenatal visits and can support normal vaginal delivery14. A district hospital is the primary referral point for all commune health centres in the district and is able to perform caesarean sections and assist vaginal deliveries. In the current study, district health centres are considered hospital delivery, and commune health centre delivery is referred to simply as ‘health centre’.
METHODS
This study comprised a retrospective descriptive study of data obtained through the Young Lives cohort study for women and their children in Vietnam.
Participants
Young Lives is a longitudinal cohort study of 12,000 children across four countries (Ethiopia, Peru, India and Vietnam), investigating the changing nature of childhood poverty over a 15-year period (2001-2016)15. For the current study, data were used from baseline assessments (2001-2002) in Vietnam, which captured a
range of sociodemographic, economic and health information (including information on pregnancy, birth and breastfeeding) for children aged 6-18 months and their households.
Sampling Method
Using purposive sampling, 20 geographic sites were selected across Vietnam, each with 100 children16. In-country experts selected sites to include key factors such as geographical location/type and particular population sub- groups. A primary target was that most sites should represent ‘poor areas’16. The sample was drawn from four regions: Northern Uplands, Red River Delta, Central Coast and Mekong Delta. Criteria for selecting regions were that the sample should: (1) consist of regions in the North, Central, and South; (2) consist of urban, rural, and mountainous areas; (3) be over-poor;
(4) refl ect some unique factors of the country, such as natural disaster and war consequences.
Five provinces from the regions were selected:
Lao Cai (North-East region), Hung Yen (Red River Delta), Da Nang (Cities), Phu Yen (South Central Coast), and Ben Tre (Mekong River Delta). Each of these provinces contains four rural clusters, except the Central Coast, which consists of four urban clusters in the city of Da Nang and another four in rural province of Phu Yen16. Eighty percent of the sample is therefore rural and 20% urban17. Where a commune had insuffi cient numbers of eligible children, a neighbouring commune with similar socioeconomic conditions was selected to reach the quota of children17. Therefore, the Vietnam study sample consisted of 31 communes within 20 sites16. .Within each geographic site, 100 households with children aged 6-18 months were randomly sampled after screening households for eligible children (twins and triplets were excluded). Where there
was more than one eligible child, one child was selected using a random sampling technique.
Selection methods ensured that each sample was indistinguishable in composition from one drawn at random from qualifying households, fi eld procedures for traversing each site were cost-effective, and there was reasonable control of bias17. A detailed description of the sampling and recruitment procedures for the Young Lives study has been published elsewhere17.
For this study, the sample consisted of 1,812 children (after exclusion of children born through caesarean section (n=187) and missing information on place of delivery for one respondent). Children born through caesarean section were removed from the sample as we sought to explore pro-active health service use.
As caesarean section could not be performed at home or a commune health centre, we chose to remove these children from the sample and focused on vaginal delivery only. As the determinants for place of birth are based on the mother’s characteristics and health seeking behaviour, the respondents are referred to as ‘women’ hereafter. The Young Lives study was approved by the London School of Hygiene Ethics Committee and ethics exemption was granted from the University of Western Australia Human Ethics Committee (RA/4/1/6827, 17/05/2014).
Data Collection
Individual questionnaire data were collected at baseline interviews (children were aged 6 to 18 months) through face-to-face interviews with mothers or caregivers where mother was not present. International experts developed core interview questionnaires to be used across the Young Lives study. Investigators from each country added country-specifi c questions16.
The questionnaire included both closed and open-ended questions and collected both textual and numeric data. During questionnaire design, respondent burden, recall error, question clarity, question order and sensitivity, and questionnaire length were considered16. The Vietnamese questionnaire was modifi ed through fi eld testing and a pilot study before being instrumented across the full cohort16,17. Data collectors
Data collection was conducted through the Research and Training Centre for Community Development (RTCCD), Vietnam; and the General Statistical Offi ce, Government of Vietnam. Fieldworkers were trained in questionnaire and interview delivery, with a focus on how to properly use the questionnaire in rural areas.
Study variables
For all participants, data were extracted from the Young Lives survey relating to sociodemographic, economic and self-reported pregnancy-related factors.
Outcome variables
The main outcome variable for this study was mother’s self-reported location (or where mother was not present caregiver’s report) of delivery, with three possible categories:
home, health centre or hospital (including private hospital). The ‘homebirth’ variable also included 58 women who had delivered at a location reported as ‘other’ (such as a relative’s home) that was not a health centre or hospital.
Explanatory variables
A range of potential determinants for maternal health service utilisation were selected based on factors infl uencing likelihood of home
birth as identifi ed in the literature6,11,12. These included sociodemographic factors such as age of mother, marital status, household head, household size, caregiver’s ability to speak Vietnamese, ethnic group (Kinh or other) geographic location (urban/rural), primary education level and wealth index. Household size was categorised into three levels: 2-4, 5-8, and 9-14 people. Ethic group initially had six categories, with Kinh being the majority ethnic group (accounting for 85%) and was collapsed into Kinh and other. Primary education level of household was a dichotomous variable (yes/no) on whether the caregiver, partner of caregiver or household head had completed primary school. Wealth Index is a proxy for household socioeconomic status used in the Young Lives study and comprised a matrix of three indices: housing quality, consumer durables, and services17 as observed by the data collector. The Index is scored between 0 and 1 whereby a higher score indicates higher socioeconomic status17. This was used to categorise households into three levels of poverty (least poor ≤0.4; very poor 0.2 to
<0.4; and poorest <0.2) consistent with other research using Young Lives study data18. Pregnancy-related factors included level of antenatal care, pregnancy experience, diffi cult labour for current pregnancy, child born before expected date, parity, and if there was a public or private hospital in the local commune. Level of antenatal care was evaluated across four levels of antenatal care (none/low/medium/
high) as described by other Young Lives research19,20. The level of antenatal care is derived from four components: (1) whether mother had any antenatal care, (2) what month of pregnancy was fi rst visit, (3) the total number of antenatal care visits, and (4) did the mother
have a tetanus injection. A mother that had their fi rst antenatal care visit at 4 months gestation or prior, had 5 or more visits and had 2 tetanus injections is considered high level antenatal care, medium antenatal care is where one of the components is not met and low is if 2 or more of the components were not met. Pregnancy experience (good/average; bad/poor), diffi cult labour (yes/no) and child born before expected due date (yes/no) were self-reported based on the mother’s perceived experience. Parity was defi ned as number of children born alive prior to the index child, with multipara being at least one previous child and grand multipara being at least four previous children. Terminations and stillbirths were not included in this calculation.
Data analyses
Descriptive statistics were performed for all variables. Fisher’s exact tests were used to determine crude differences in the proportion of response categories for all possible comparisons between study outcome (ie. birth location: home, health centre or hospital). One- way ANOVAs with Tukey post-hoc analysis were used to evaluate differences in continuous variables such as maternal age.
Multinomial logistic regression modelling was used to explore the pregnancy-related and sociodemographic determinants for delivery at a commune health centre or hospital compared to home birth with odds ratio (ORs) and 95%
Confi dence Intervals (95% CI) calculated.
Fisher’s exact tests showed signifi cance for a number of variables between hospital and health centre delivery, providing a rationale for the use of a multinomial model instead of a binary logistic regression model (home birth vs. institutional delivery). A backward stepwise variable selection method was used,
beginning with a saturated model including all explanatory variables (with the addition of an age2 term to account for non-linearity in the data) with progressive removal of factors until the most parsimonious model was achieved.
All data were analysed using SPSS version 2221 statistical software.
RESULTS
Characteristics of the study sample are shown in Tables 1 and 2. Most women in the study spoke Vietnamese (95%), were of Kinh ethnicity (85%), lived rurally (83%), had at least one household member who had completed primary education (84%), were in the highest wealth index group (56%) and were multiparous (55%). The mean (±SD) age of participants was 27 years (SD=5.6). Most women reported a good/average pregnancy experience (83%), did not have a diffi cult labour (86%), and did not give birth before expected (86%), with 90% reporting a public hospital available in the community (Table 2).
Overall, most women reported an institutional delivery [hospital n=813 (45%); health centre n=563 (31%)], and 24% (n=436) of women gave birth at home. Table 3 details the level of skilled attendance at delivery across birth setting. Women delivering at home were predominately from rural areas (98%), among the very poor and poorest women (73%), had no antenatal care (53%) and were multiparous (64.4%) (Table 1 and 2). Seventy-two percent of women from an ethnic group other than Kinh delivered at home birth (Table 1).
Signifi cant differences in the proportion of women delivering at health centre compared to hospital for a number of factors were seen
including, geographical location (hospital: 25%
urban, 75% rural; health centre: 17% urban, 83% rural), primary education level (hospital:
one member completed 88.8%, no member completed 11.2%; health centre: 92.6% vs 7.4%), wealth index (hospital: least poor 57.4%, very poor 29.5%, poorest 13.1%; health centre 71.1%, 20.5%, 8.4% respectively), level antenatal care (hospital: none 15%, low 25.3%, medium/high 60.7%; health centre: 22.9%, 28.4%, 48.7%, respectively), diffi cult labour (yes - hospital:
18.5%; health centre 9.7%), parity (hospital:
primipara 51.4%, multipara 48.8; health centre 41.7%, 58.2%, respectively) and private hospital in community (yes – hospital: 7%; health centre 22% (Table 1 and 2).
Table 3. Type of skilled attendant at birth across birth setting, n (%)
Birth Setting
Home Commune Health Centre Hospital
Skill Type N % n % n %
Total Unskilled 222 50.9 36 6.4 57 7.0
TBAd 39 8.9 11 2.0 1 0.1
Total Skilledc 191 43.8 501 89.0 732 90.0
Midwife 14 3.2 66 11.7 49 6.0
Nurse 131 30.0 371 65.9 222 27.3
Doctor 46 10.6 38 6.7 461 56.7
Skill unknown 23 5.3 26 4.6 24 3.0
Total 436 100.0 563 100.0 813 100.0
cHighest level skill present at birth as reported by mother/caregiver.
dTBA – traditional birth attendant
Results from the multinominal logistic regression modelling are shown in Table 4.
Women who were from an ethnic group other than Kinh had signifi cantly lower odds of commune health centre (OR=0.1; 95% CI 0.1- 0.2; p<0.001) and hospital delivery (OR 0.2;
95% CI 0.1-0.4; p<0.001) compared to Kinh women. Households with one member who
Table 1. Sociodemographic characteristics of respondents
Characteristic
All Place of birth p-value Fisher’s exact
n % Homebirth Commune health
Centre Hospital Home vs centre Home vs hospital Centre vs hospital
N % n % n %
Age (mean [SD]) 27 [5.6] 27 [5.9] 26 [5.3]b 27 [5.6] 0.012a
Marital Status 0.514 0.837 0.321
Permanent partner 1769 97.6 428 98.2 544 96.6 797 98
Divorced/separated 20 1.1 3 0.7 8 1.4 9 1.1
Single/widowed 23 1.3 5 1.1 11 1.9 7 0.8
Household head 0.197 0.001 0.068
Caregiver 120 6.6 31 7.1 33 5.9 56 6.9
Caregiver’s partner 1240 68.4 321 73.6 396 70.3 523 64.3
Other 452 24.9 84 19.3 134 23.8 234 28.8
Household size 0.135 0.247 0.777
2-4 people 963 53.1 214 49.1 310 55.1 439 54
5-8 people 748 41.3 194 44.5 226 40.1 328 40.3
9-14 people 101 5.6 28 6.4 27 4.8 46 5.7
Caregiver can speak
Vietnamese p<0.001 p<0.001 1
Yes 1716 94.7 341 78.2 563 100 812 99.9
No 96 5.3 95 21.8 0 0 1 0.1
Ethnic group p<0.001 p<0.001 0.289
Kinh 1536 84.8 236 54.1 535 95 765 94.1
H’mong 113 6.2 109 25 0 0 4 0.5
Dao 34 1.9 22 5 4 0.7 8 1
Nung 30 1.7 15 3.4 7 1.2 8 1
Tay 21 1.2 9 2.1 2 0.4 10 1.2
Other 78 4.3 45 10.3 15 2.7 18 2.2
Geographic Location p<0.001 p<0.001 p<0.001
Urban 308 17 10 2 96 17 202 25
Rural 1504 83 426 98 467 83 611 75
Primary education
level of household p<0.001 p<0.001 0.016
One member
completed 1513 83.5 260 59.6 500 88.8 753 92.6
No member
completed 299 16.5 176 40.4 63 11.2 60 7.4
Wealth Index p<0.001 p<0.001 p<0.001
Least poor 1019 56.2 118 27.1 323 57.4 578 71.1
Very poor 474 26.2 141 32.4 166 29.5 167 20.5
Poorest 318 17.5 176 40.5 74 13.1 68 8.4
Missing 1 0.1
aOne-way ANOVA with Tukey post-hoc; bp<0.05 with home group
Table 2. Pregnancy-related characteristics of respondents
Characteristic
All Birth Setting p-value Fisher’s exact
n % Homebirth Commune
Health Centre
Hospital Home vs Centre
Home vs hospital Centre vs hospital
Level antenatal care N % n % n % p<0.001 p<0.001 p<0.001
None 477 26.3 232 53.2 126 22.9 119 15
Low 440 24.3 91 20.9 156 28.4 193 24.3
Medium/high 852 47 101 25.9 268 48.7 483 60.7
Missing 43 2.4
Pregnancy experience 0.002 0.058 0.119
Good/average 1510 83.3 345 79.1 487 87.3 678 84.2
Bad/poor 285 15.7 87 20 71 12.7 127 15.8
Missing 17 1
Diffi cult Labour 0.433 p<0.001 p<0.001
No 1558 86 398 91.9 504 90.3 656 81.5
Yes 238 13.1 35 8.1 54 9.7 149 18.5
Missing 17 0.9
Child born before expected
0.003 p<0.001 0.113
No 1557 85.9 397 91.1 484 87.7 676 84.6
Yes 219 12.1 28 6.4 68 12.3 123 15.4
Missing 36 1.8
Parity
Primiparous 781 43.1 128 29.4 235 41.7 418 51.4 p<0.001 p<0.001 p<0.001
Multipara 998 55.1 281 64.4 325 57.7 392 48.2
Grand Multipara 33 1.8 27 6.2 3 0.5 3 0.4
Public hospital in community
p<0.001 p<0.001 0.504
Yes 1624 89.6 336 77 524 93 764 94
No 188 10.4 100 23 39 7 49 6
Private hospital in community
p<0.001 p<0.001 p<0.001
Yes 215 11.9 2 0 37 7 176 22
No 1597 88.1 434 100 526 93 637 78
had completed primary school had greater odds of commune health centre (OR=1.7; 95%
CI 1.1-2.5; p=0.023) and hospital delivery (OR=2.1; 95% CI 1.3-2.9; p<0.001) compared to households with no primary education. Age, marital status, household head and household size were not signifi cant determinants for either commune health centre or hospital delivery.
Decreasing wealth was associated with signifi cantly decreased odds of hospital delivery, with a 54% reduction in hospital delivery for the poorest group compared with the least poor group; however, wealth had no signifi cant effect on health centre delivery. Women who lived in a rural area had lower odds (OR=0.29;
95% CI 0.13-0.66) of health centre delivery, compared to their urban counterparts; however, this was not the case for hospital delivery.
Pregnancy-related factors
Increasing parity was associated with a 37-57%
decrease in health centre (37%) or hospital delivery (57%) for multipara women compared with primipara women, and a further reduction in odds (between 75-80%) for grand multiparous women for healthcare centre and hospital delivery respectively, although the result for grand multipara women and health centre delivery only approached signifi cance (p=0.056). Child born before expected was associated with a 1.7-fold (OR=1.7; 95% CI 1.0-2.9; p=0.041) increased likelihood of health centre delivery with similar results for hospital delivery (OR=1.95; 95% CI 1.16-3.37; p=0.012) (Table 4).
Increasing level of antenatal care was associated with a 3.5-fold increased likelihood of hospital delivery for women receiving medium/high care (OR=3.5; 95% CI 2.4-5.1; p<0.001) compared to those receiving no antenatal care,
compared to just 2.1-fold increase for health centre (OR=2.1; 95% CI 1.5-3.1; p<0.001).
Women experiencing a diffi cult labour were twice as likely to have a hospital delivery, than health centre delivery, compared to women who did not report experiencing any diffi culty.
The strongest determinant for health centre delivery was having a public hospital (not including health centres) in the community (OR=2.5; 95% CI 1.6-3.9), while the highest odds of hospital delivery (which also included private hospitals) was seen for having a private hospital in the community (OR=20.5; 95% CI 3.9-106).
DISCUSSION
This study contributes valuable information about the determinants of delivery service use in Vietnam. Our hypothesis that women from ethnic minorities, with higher parity, lower household education level and lower level antenatal care, would be less likely to have institutional delivery was supported, and is consistent with fi ndings from previous studies in low income countries11 and for absence of skilled birth attendants6,9,10. However, the current fi ndings are unique in demonstrating that different factors infl uence the likelihood of delivery at a health centre or hospital. For example, living rurally decreased the odds of health centre delivery but not hospital delivery (compared with home birth as the reference), whereas a higher wealth index increased the likelihood of hospital delivery but had no signifi cant effect on health centre delivery.
For women with a lower wealth index, hospital delivery may have posed a greater fi nancial burden than health centre delivery. Despite recent government initiatives launched in
Table 4. Odds of institutional delivery (multinomial model) **
Health centre Hospital
Correlates OR 95% CI P-value OR 95% CI P-value
Household size
2-4 people 1 1
5-8 people 1.2 0.9 1.7 0.258 1.3 1.0 1.8 0.078
9-14 people 2.0 0.9 4.3 0.083 2.0 0.9 4.4 0.074
Ethnic group
Kinh 1 1
Other 0.1 0.1 0.2 p<0.001 0.2 0.1 0.4 p<0.001
Geographic Location
Urban 1 1
Rural 0.3 0.1 0.7 0.003 1.0 0.4 2.5 0.977
Primary education level of household
No member completed 1 1
One member completed 1.7 1.1 2.5 0.023 2.1 1.3 3.3 0.001
Wealth Index
Least poor 1 1
Very poor 0.9 0.6 1.3 0.589 0.6 0.4 0.8 0.003
Poorest 0.8 0.5 1.3 0.452 0.5 0.3 0.7 0.001
Level antenatal care
None 1 1
Low 1.6 1.1 2.3 0.027 1.9 1.3 2.9 0.001
Medium/High 2.1 1.5 3.1 p<0.001 3.5 2.4 5.1 p<0.001
Diffi cult Labour
No 1 1
Yes 2.2 1.3 3.9 0.004 5.2 3.1 8.7 p<0.001
Child born before expected
No 1 1
Yes 1.7 1.0 2.9 0.041 2.0 1.2 3.3 0.012
Parity
Primipara 1 1
Multipara 0.6 0.5 0.9 0.005 0.4 0.3 0.6 p<0.001
Grand Multipara 0.3 0.1 1.0 0.056 0.2 0.1 0.8 0.022
Public hospital in community
No 1 1
Yes 2.5 1.6 4.0 p<0.001 2.6 1.7 4.1 p<0.001
Private hospital in community
No 1 1
Yes 1.7 0.3 8.9 0.509 20.5 4.0 106.0 p<0.001
**Home birth is reference group; CI, confi dence interval; OR, odds ratio; 1 = reference category Ethnic group collapsed due to low response in health centre outcome
Caregiver cannot speak Vietnamese removed due to low response rate in health facility and hospital categories
Household head removed as worse fi t (p<0.001), pregnancy experience removed as worse fi t (p<0.001), age and age*age removed as worse fi t (p<0.001)
Vietnam aiming to provide healthcare to all poor individuals and households22, a contributing factor to the under-utilisation of maternal health services is high costs as well as ‘informal’ fees reported in other countries to constitute 5-10 times offi cial salaries for health workers23. In Vietnam, health centre delivery had been described as ‘cheap and affordable’
compared to hospital delivery, which was considered ‘expensive’22.
Health service availability
The strongest determinant for hospital delivery (public or private hospital) in the current study was having a private hospital in the commune, however, we cannot determine whether women delivered at a private or public facility, limiting relevance for the provision of delivery services through the public sector in Vietnam.
Nevertheless, our results reveal differences in health service utilisation across the health sector in general. The 2002 Vietnam Demographic and Health Survey (DHS) reported that 75%
of women delivered in a public facility and 4% delivered in a private facility24, and it is probable that our study sample has similar proportions based on its representativeness to the wider Vietnamese population as reported elsewhere17.
Family size policy
We found women who had fi ve or more births were less likely to give birth in a health centre or hospital than those who had experienced fewer births. This is consistent with previous research which has reported associations between higher parity and lower skilled birth attendance as well as increased home delivery in other South-east Asian settings10,25. This is likely explained by the fact that women with high parity will have previous birth experiences
to draw on, impacting the decision-making process for place of delivery. In addition, the 1993 National Population Policy suggested Vietnamese families to have one to two children with birth spacing of three to fi ve years26,27. Consequently, women with more than two children or with close birth spacing in our study may have been deterred or restricted from having an institutional delivery due to fear of discrimination by health care workers as reported elsewhere in Vietnam22.
Antenatal Care and Labour
In Vietnam, positive experiences with ANC increase likelihood of institutional delivery22. Women who had a medium/high level of ANC were 60% more likely to deliver at hospital than a health centre, perhaps because ANC increases knowledge about risks of childbirth and emphasises the importance of skilled birth attendance and institutional delivery11,28. A secondary explanation may be that women using regular ANC may be those experiencing risk factors for pregnancy complications, who were subsequently referred to hospital for delivery28 thus explaining the fi nding.
Women who experienced a diffi cult labour were twice as likely to deliver at hospital compared to a health centre. Similarly, a Cambodian study found women who experienced prolonged labour were 6.5-times more likely to eventually have institutional delivery10. Women who experienced a diffi cult labour would have likely sought or been referred to higher level care as complications arose. However it is important to note that only women with surviving children were sampled in this study, so maternal and neonatal mortality may be high among women who experienced a diffi cult labour but who could not access institutional care.
LIMITATIONS
The provision of maternity services does not necessarily translate into their use1,22, and the perceived quality and benefi t of services should also be considered22. In terms of quality, the 2003 Safe Motherhood National Field Assessment found that 45% of commune health centres in Vietnam were not operating full time, had under-skilled service providers and were under-resourced in essential obstetric equipment12. These factors were not evaluated in our study but may have played a role in the decision making process for delivery.
Another limitation is the self-reported nature of the data. For example, women may have difficulty identifying whether the health professional present at birth was a nurse or midwife as well as the actual competence of the health service provider33,34. However we are confi dent that the women would be able to recall the place of birth accurately. Method triangulation was used where possible, for example the calculation of wealth index involved both self-reported information on quality of housing from the woman, which was confi rmed through observation from the data collector. Some variables, which are known determinants for maternal health service use, such as distance between home to closest health facility and quality of roads/transport11, were not collected and therefore could not be included in the analysis.
The use of pro-poor sampling potentially limits the external validity of the study. Compared to the DHS 200235, more than 60% of the Young Lives sample have a wealth index score below the mean compared to 30% for the DHS sample17. However, home, health centre and hospital delivery rates were similar in the
Young Lives and the DHS sample in 200117, 24%, 31%, 45% compared to 20%, 30% and 50%, respectively. The Vietnamese government has a strong focus on pro-poor initiatives in the health sector, therefore, having a pro-poor focus allows for the impact of such reforms to be explored. The inequalities observed due to economic factors in the study may be stronger at a whole-population level, although this cannot be directly estimated from the data available.
Relevance to the current context and research to date
Economic growth in Vietnam has accelerated since the ‘economic renovation’ (doi moi) beginning in 1986. Not only did the incidence of poverty fall36 but doi moi had a strong focus on pro-poor initiatives in the health sectors rendering health care available for to all poor households23. The national poverty rate fell from 58% in 1993 to 20.7% in 2010, and Vietnam achieved Millennium Development Goal One, halving income poverty by 199837. This is refl ected in the decrease in the proportion of women delivering home to 7.9%
in 2011 estimates. The home birth rate of 24%
in the current study is higher than more recent estimates and indicates that Vietnam has made progress increasing institutional delivery since the time of data collection for the current study.
However, poverty reduction has not been uniformly distributed across regions (rural/
urban) or along ethnic lines23,38. In fact, the share of ethnic minorities among the poor across Vietnam indicates poverty persistence in the minority groups36,37 in addition rural regions are generally poorer than urban regions36. Poorer maternal health service use is experienced in these groups to date6,23,39. It is well established that social and health inequities persist across generations and that patterns of inequity are
generally consistent over time29-32 remaining a challenge in health service delivery.
To date, there have not been any studies that have explored health centre and hospital delivery separately, however there has been a recent series of work in Vietnam examining inequities in health service use6,23,39. These studies revealed persistent inequities in maternal health service utilisation in Vietnam, particularly for ANC and skilled birth attendance along ethnic and rural/
urban lines6,23,39. These more recent fi ndings are consistent with the fi ndings of the current study and previous published work. Recent data in Vietnam found that women from ethnic minority groups are signifi cantly more likely to deliver at home than majority groups6. One reason for this may be that ethnic minority women feel that they are treated poorly in health care settings as reported in recent studies22,23. Recent work from Vietnam has also found that women who had at least four ANC visits were four-times more likely to have institutional delivery than women who had none, which increased to 11-times more likely for women who had seven or more ANC visits12, this is also similar to the fi ndings in the current study, indicating that this trend has not changed over time.
CONCLUSIONS
This study found that sociodemographic and pregnancy-related determinants for health centre and hospital delivery were different for a number of factors in this population, having important implications for policy development.
For example, reducing direct and indirect costs may be successful at reducing barriers for hospital delivery but may have no impact on health centre delivery. The promotion of ANC
to all women and delivery services to multipara women is particularly important. These should be accompanied by redistributive policies to decrease the inequity in maternal health service utilisation between disadvantaged groups (ethnic minorities and the rest of the population) that still persist. Our fi ndings suggest that inequities in the type of delivery service used exist between disadvantaged groups and the rest of the population.
DECLARATION OF CONFLICT OF INTEREST
The author(s) declared no potential confl icts of interest with respect to the research, authorship, and/or publication of this article.
ACKNOWLEDGEMENTS
Young Lives is funded by UK aid from the Department for International Development (DFID), with co-funding from 2010 to 2014 by the Netherlands Ministry of Foreign Affairs, and from 2014 to 2015 by Irish Aid. The views expressed here are those of the author(s). They are not necessarily those of Young Lives, the University of Oxford, DFID or other funders.
We are grateful for funding provided through the Governor Sanderson Scholarship in Population Health (Dr Haruhisa Handa Leadership Scholarship Program) to support this research and travel to Vietnam. The second author is supported by a National Health and Medical Research Council of Australia Early Career Fellowship.
We sincerely thank all women who participated in this study and Duc Le Thuc for providing feedback on the interpretation of fi ndings.
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