Inequity in maternal health care utilization in Vietnam

ResultsIn Vietnam, inequities in maternal health care utilization persist due to poverty, low education and ethnic minority status. These structural determinants were all related to ANC and SBA coverage - with ethnicity as the key driver of inequity.

Ethnic minority women form a clearly disadvantaged group that tends to reside in rural areas, lack education and live in poor households. Their high risk of not receiving maternal health care persisted in this time of transition.

Ethnicity was found to be associated with SBA - independent of wealth. Less than half of ethnic minority women had SBA/delivered at a health facility, while almost all ethnic majority mothers had. In an ethnic minority group, low education further increased the risk for mothers of not receiving ANC, and poverty made them six times more likely to deliver without SBA and three times less likely to attend any ANC.

Changes in maternal health care utilization (e.g. ANC) took place in the rural population mainly - almost all urban mothers had attended ANC anyway. Ethnic minority mothers stayed at a significantly higher risk because improvements in maternal health care were not equal to those in the better-off groups.

Among other barriers identified for health care utilization were traditional practices and rituals surrounding birth, perceived negative attitudes from health personnel, and feelings of disempowerment and voiceless. Informal payments, a growing private sector and weak public health insurance policy also caused inequities based on the ability to pay for services.

Policy considerations• Find more efficient ways to target disadvantaged groups while considering multiple

synergy effects between determinants wealth, education and ethnicity.• Involve ethnic minority groups in planning and implementation of interventions, e.g.

through open dialogues. • Strengthen cultural and linguistic sensitive interventions for ethnic minority groups. • Collect reliable information on incidence and causes of maternal mortality to enable

promotion of maternal health and survival.• Make parallel investments in other sectors than health care, such as education, income generating activities, women empowerment and infrastructure, in order to promote safe motherhood.• Work towards poverty alleviation to improve the provision of maternal health services.

"Women who belonged to an

ethnic minority and were living

in a poor household had an almost

10-fold risk of not receiving

antenatal care, as compared to

ethnic majority women living in a

non-poor household."

Key messages• Large inequities exist due

to poverty, low education and - above all - ethnic minority status.

• Associations between ethnicity and lack of antenatal care are independent of wealth.

• Ethnic minority women are at highest risk of not utili-zing maternal health care.

• Despite improvements in

maternal health care utilization, ethnic minority mothers stay at higher risk.

Two survey data analyses on utilization of antenatal care (ANC) and skilled birth attendance (SBA) in relation to wealth, education and ethnicity with the aim to reveal health inequities.

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Keywords Antenatal care, ethnicity, health care utilization, inequity, maternal health, skilled birth attendance, social determinants of health, Vietnam

Rationale of the studyDisadvantaged groups of women tend to have higher rates of morbidity and mortality related to pregnancy and childbirth, and less access to safe, affordable and acceptable health care services. This “hidden” ill-health adds to the challenge of reaching Millennium Development Goal (MDG) 5 to reduce maternal mortality by 2015.

Vietnam is a country that is in the middle of an economic and demographic transition with a grow-ing economic and public sector. The proportion of people living below the poverty line has reduced significantly, but among less affluent groups and ethnic minorities the rate of poverty reduction has been lower. Ethnic minority women in Vietnam make up a highly heterogenic group of ethnicities with differences in culture, language, residence, wealth and education levels [1].

Following the economic transition in the 1980s, there was a decline in maternal mortality ratio (MMR) from an estimated 170 in 1990 to about 70 in 2009 [2]. However, analyses indicate conside-rable inequities between social groups in Vietnam. According to data from 2000-01, ethnic minority groups had an MMR that was almost 4 times the size of that in the ethnic majority group [3]. In 2009, UNICEF published a report on inequities in maternal and child health in Vietnam, which revealed that although maternal health had improved over time inequalities still existed between disadvantaged and privileged groups [4]. There is a need to better understand the relative impor-tance of social determinants of health and their potential synergy effects, in order to target resour-ces efficiently and achieve MDG 5 in an equitable manner. Also, there is a need to understand changes over time in the equity gap of ANC attendance, SBA and health facility delivery rate.

MethodsData from the Multiple Indicator Cluster Survey in Vietnam in 2006 (MICS3) and 2011 (MICS4) was analyzed through stratified logistic regressions and g-computation. The aim was to find differen-ces in maternal health care utilization (i.e. antenatal care coverage, skilled birth attendance/place of delivery - institutional or at home) based on the structural determinants mother's income, educa-tion, place of residence and ethnicity [5,7]. The structural determinants are based on the social determinants of health according to the Commission on Social Determinants of Health (CSDH) framework set up by WHO [6].

MICS3 and MICS4 cover a total of 8,356 and 11,642 households respectively representing 8 regions in Vietnam. Women of reproductive age (15–49 years) were interviewed about demographic characteristics, reproductive history, pregnancy, postnatal care, immunization and nutrition. Most of the women interviewed for MICS4 had a higher socioeconomic status, better education, residence in an urban area and affiliation to the ethnic majority, compared to MICS3. There was an overall higher utilization of maternal health services in MICS4, but the equity gaps persisted and the difference in health facility delivery rate based on socioeconomic status remained unchanged.

EPI-4 is a partner-driven coopera-tion for intensifying efforts to reach the health-related MDGs in China, India, Indonesia and Vietnam through evidence for policy and imple-mentation (2011-13). It is funded by the Swedish International Develop-ment Cooperation Agency (Sida). The pro-ject focuses on disadvantaged populations, highlighting the need for greater equity in achievement of the MDGs. In Sweden, Karolinska Institu-tet, Gothenburg University, Umeå University and Uppsala University are participating. The project part-ners are Fudan University (China), University of Gadjah Mada (Indo-nesia), the Public Health Institute of India, and the National Pediatric Hos-pital of Vietnam.

Selected literature

1. Country Social Analysis: Ethnicity and social development in Vietnam. Summary report. Washington, D.C: The World Bank; 2009. 2. Trands in maternal mortality: 1990-2008. Geneva: World Health Organization; 2010.3. Maternal mortality in Vietnam 2000-2001: an in-depth analysis of causes and determinants. Hanoi: WHO; 2005.4. Knowles JC, Bales S, Cuong LQ, Oanh TTM, Luon DH: Health Equity in Viet Nam: a situation analysis focused on maternal and child mortality. Background paper prepared for the UNICEF Consultancy on Equity in Access to Quality Healthcare for Women and Children, April 8–10, 2009. UNICEF: Ha Long, Viet Nam; 2009.5. Goland E, Hoa DTP, Målqvist M. Inequity in maternal health care utilization in Vietnman. BMC Public Health. 2012, 11;24.6. Commission on Social Determinants of Health: A Conceptual Framework for Action on the Social Determinants of Health. Geneva: World Health Organization; 2007. 7. Målqvist M, Lincetto O, Nguyen HD, Burgess C, Hoa DTP. 2012. (Submitted to WHO Bulletin.)

Correspondence

Dinh Thi Phuong Hoa, MD PhDphuonghoa55@yahoo.comHanoi School of Public Health, Hanoi, Vietnam

Mats Målqvist, MSS MD PhDmats.malqvist@kbh.uu.seInternational Maternal and Child Health,Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden

Research brief created by Olivia Biermann, MScolivia.biermann@ki.se

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