Tuong, 32, delivered her first two children at home on her own. She hopes to deliver her third with the help of a skilled midwife and medicine. Photo: Laura Vinha/UNFPA

21 May 2007

BINH DINH PROVINCE, Viet Nam — Tuong is home on her own in a remote village in the lush green mountains of central Viet Nam when her son decides the time is now – he wants out of her womb and into this world. Twenty-year-old Tuong knows no one will hear her scream. The life of her son is in her hands alone.

“No one helped me when I had my baby at home. My husband and my mother were in the field when I gave birth,” says Tuong in a quiet voice, her brown-eyed gaze steady on the tiled floor of the Vinh Hoa Commune health clinic.

Five years later, this small woman, who has spent her life working in the fields, was once again left to her own devices with the birth of her daughter.

Tuong, now 32 years old and seven months pregnant with her third child, has few words to share. There were no complications. Just pain.

“I worked until the last day that I had the babies. It was very hard. I was very tired. One month later, I went back to the farm work and took my baby with me,” she says. There was no clinic in or near her home village, which has since made way for a hydroelectric power plant, a symbol of the whirlwind journey of change and development Viet Nam is going through.

Tuong says her relocated village is now within walking distance of the clinic. Like the other young women here, she wants less pain and more help with her next delivery.

“I think and I hope that to have a baby at the clinic is better than at home,” she says, and finally the hint of a smile touches her work-hardened face.

I think and I hope that to have a baby at the clinic is better than at home --Tuong

The number of Vietnamese women who die giving life has decreased over the past few years. But while national maternal mortality ratio estimates vary from 130 to 165 deaths per 100,000 live births, studies indicate that in some mountainous provinces, where women predominantly give birth without professional help, the figure is up to three times as high. Haemorrhage is the most common killer of mothers who die of obstetric complications.

Ethnic minority women – like Tuong and her Ba Na sisters in Binh Dinh Province – are the most vulnerable as they often live in remote areas where there is a lack of clinics and trained birth attendants. Where facilities exist, they are insufficiently equipped and staffed. Ethnic minority women and men are also less likely than the majority Kinh to use or have access to modern contraceptives. With 54 ethnicities, each with their own traditions and languages, finding solutions that will serve all is a challenge for Viet Nam.

Tuong has been very strong. She has also been very lucky.

At the commune clinic, where Tuong is waiting for a routine check-up, equipment has just been upgraded and one of the four health workers recently received training in obstetric care. Two of the staff are Ba Na, which they hope will encourage ethnic minority women to use the services. The clinic – supported by the New Zealand aid agency NZAID and UNFPA, the United Nations Population Fund – hopes to experience its first delivery this year.

Pioneering change

An untamed tangle of electricity cables along the bumpy but paved road that leads to Vinh Hoa is a sign of progress in this sleepy commune of wild shrubs, misty mountains and bright green fields. And Hdop, a 47-year-old Ba Na mother of five, is a woman who symbolizes both the old and the new, holding on to the traditions that count while embracing the changes that she knows will benefit her family.

Hdop, 47, is an advocate of women's rights and modern medicine. She delivered all 5 of her children, including her 2 daughters, at a clinic. Photo: Laura Vinha/UNFPA

She did not want to move from her traditional bamboo stilt house to a brick one that was built for her. But unlike most of her peers, she has delivered all of her children with the help of trained staff at a clinic or hospital.

“I saw many of my friends who listened to their husbands and had to have their children at home. They are my age, but they are not as strong as me,” says Hdop, letting out a roar of laughter.

Hdop is an active member of the local women’s club where she tells young women not to listen to their husbands too much. “Because when the men drink too much, they will ask you to do things that are bad for your health. I tell the women to have regular health check-ups.”

She follows her own advice. When Hdop discovered she had a sexually transmitted infection, she got medicine for both herself and her husband who refused to accompany her to the clinic.

Hdop also tells the men in her community to listen to the radio to learn about sexually transmitted infections and HIV, and about ways to protect themselves and their wives. Her advice to her three sons is: “Try to make friends with one girl only.”

Viet Nam, with an estimated population of 85 million, has encouraged couples to have two children or less in an effort to slow population growth, and small families are the norm in the Communist country whose people are expected to number 100 million in the next 15-20 years. Outside the Vinh Hoa clinic, a propaganda billboard hails the progress and happiness that will come to families with few children

Hdop, too, planned to have two children, but after two sons, she and her husband decided to have a third child, aiming for a daughter. While for Viet Nam’s majority Kinh it is important to have a son to carry on the family name and commemorate ancestors, the Ba Na desire daughters as girls are the ones who stay to help their parents in old age.

“Our third was also a son. That’s why my husband asked me to try to have the fourth one,” says Hdop, whose two youngest children are girls.

Tre (l), 24, delivered her 5-year-old daughter at home. Her friend Linh (r), 20, is 4 months pregnant with her first child and intends to deliver at the local clinic. Photo: Laura Vinha/UNFPA

“The fifth one – that was because my husband was drunk!” says Hdop, rocking with laughter and explaining they were using condoms for contraception at the time. “My husband had been drinking and he said, ‘We don’t need those now!’ That was number five.”

Hdop’s neighbour, Xuan, a 50-year-old Kinh woman and mother of four boys, welcomes the improvements this part of the country has seen in the 28 years since she first gave birth in the mountains with the help of a traditional birth attendant.

“After the delivery, she gave me traditional herbal remedies, but that’s all. The last two I had at the clinic with medicine and better care,” Xuan says. “I think the first two children, it was up to God. God saved them. For the last two, the nurse helped me a lot.”

Xuan’s face turns grave as she talks about her home village in the mountains where many women and babies died from obstetric complications due to lack of professional care.

“My uncle’s wife died because she had a baby that would not come out. At that time, if there were complications in a delivery, people would make offerings – even big pigs – but still the mothers died,” Xuan says.

While the women who come to the rural clinics for check-ups appreciate the new services, including the outreach work done by the local health workers, staff at these clinics admit many more improvements are needed. They are overworked, they want more training, they want better equipment and supplies. Staff at the district level also say it will take time to get women to use their services.

“The health workers know the high risks, but how do we convince the women?” asks Hang, a midwife at the Vinh Thanh District Health Centre, some 80 kilometres from the provincial capital of Quy Nhon.

At the Vinh Thuan Commune clinic, some five kilometres away, 20-year-old Linh insists there is no need for convincing: once the services exist, she and other Ba Na women her age will use them. Linh is four-months pregnant with her first child, and at her first check-up has received folic acid and iron tablets. Like most expectant mothers, she is exited about the new life that is growing inside her.

“I feel very happy. I will have my baby here. Our generation, we prefer to have babies at the clinic,” Linh says smiling widely.

— Laura Vinha