Five to seven women still die almost every day due to pregnancy or childbirth in Viet Nam. Although the maternal mortality ratio has declined significantly over the past few years, there are still big differences between regions – from a low of 40 up to 410 deaths per 100,000 live births in some areas. The highest ratios are found in remote and mountainous ethnic minority areas of the country, partly due to the shortage of skilled birth attendants and health care workers in these areas. Cultural barriers also keep many of the women in these areas from using reproductive health services. To address this issue, UNFPA is supporting an initiative to recruit and train local women to become village-based midwives.
MA DU VILLAGE, Ninh Thuan Province, Viet Nam – After doing some chores on her small farm, Cha Ma Lea Thi Te puts down her farming equipment, washes her hands thoroughly, picks up a kit that includes supplies for an uncomplicated delivery and takes off to visit her clients. She is one of 49 graduates of the 18-month midwife training programme for ethnic minority women supported by UNFPA, the United Nations Population Fund, in three mountainous provinces.
Combining theory and practice, this pilot programme works to improve antenatal and primary health care services at village and commune levels, and thus contribute to reducing maternal and child mortality among ethnic minority people.
Right after finishing the training last March, Te, who belongs to the Rac Lay ethnic group, started to provide health care services in her village. She has quite a busy schedule now. From Monday to Friday she makes house calls, and when needed goes to the commune health centre to support health workers and continue her learning. Te still has to find time for farming since with income she receives from working as a village-based midwife is not enough to make ends meet. But she is happy: not only has her life changed, but she is also improving the lives of many other women in her village.
”Thanks to the training, I have gained skills and knowledge about maternal health,” she says. “Now I feel confident providing family planning services, pre- and post-natal care and attending normal deliveries. For complicated cases, I know how to refer them to higher levels so they can get [the needed] care.”
Te’s work is closely monitored by officials at the community health centre, where Loan, the chief midwife, supervises and guides Te and two other village-based midwives. “Their performance is excellent and they are very enthusiastic,” says Loan.
Overcoming the pull of tradition
Understanding the language, the culture and the belief system of an ethnic group is key to gaining trust and encouraging women to receive appropriate health services. “Women are satisfied with my work,” Te says with certainty. “They trust me for several reasons: I was born and grew up in this village. Therefore they know me, and they also know that I am a skilled birth attendant. And we belong to the same ethnic minority group and speak the same language.”
All these factors have made it easier for Te to approach women in her village in order to provide health education, counselling and related services. This in turn has contributed to overcoming certain traditions that have prevented mothers from accessing maternal health services.
For example, until recently, Rac Lay women delivered in the forest, far away from health facilities and assisted only by their mothers and traditional birth attendants. Before giving birth they used to build a shelter close to a tree where they delivered. They stayed in this basic refuge at least three days. After the delivery, they collected and boiled tree bark that they believed would help to stop the bleeding.
Although the practice of drinking the liquid persists, most pregnant women now prefer to have skilled birth attendants attend their deliveries. “The number of women coming to the commune health centre for check ups and deliveries is increasing day by day,” explains Chamale Vuong, head of the commune health center in Phuoc Thanh Commune. This is due to the awareness raising campaigns on safe motherhood carried out by local authorities and mass organizations, and also because of the work done by the ethnic minority midwives.
Te and her colleagues at the health centre also actively participate in a ‘community-based referral team’ set up to transfer pregnant women or mothers and their babies to the health centre when needed. “We also have a breastfeeding club at the commune level where mothers can access information on nutrition, child and maternal health, hygiene and injury prevention,” Vuong adds.
Attending normal deliveries and providing pre- and post-natal care
Chemale Thi Cuc is now 24 years old. She was born in a forest where her mother delivered her assisted by a traditional birth attendant. “At that time there was no commune health centre,” says Cuc. “Things have improved over the years. When my first baby was born four years ago, the commune health centre existed but we barely knew about the services provided, and this is the reason I delivered at home.” Three months ago, Cuc delivered her second child, this time attended by Te and Cha Ma Lea Thi Hem, another recent midwife graduate based in the same village. Both of them visit Cuc’s household regularly during her pregnancy. “Everything went as planned and the mother and her daughter are now in perfect shape,” Te says during the visit.
“We do not have to worry anymore,” says Cuc’s husband. “Since the time my wife got pregnant until now, both village-based midwives have visited her, providing care before, during and after childbirth,” he adds. “They encouraged us to go to the commune health centre for the delivery and after they have been coming to visit us once per week to ensure that everything is fine and to provide us with counselling on family planning and nutrition.”
Fifteen-year-old Chamale Thi Lem, who is eight months pregnant with her first child, lives nearby and is being monitored by the village-based midwives. Lem has been to the commune health centre twice and has had check ups at her house on three other occasions. Because she is so young, this is a somewhat risky pregnancy, but “everything is going smoothly,” says Hem while checking the blood pressure of the young mother. “Since this is a normal case with no complications, we follow the common steps. First we check the blood pressure, measure the belly and see if the [mother’s] feet and legs are swollen. We also check to see that the baby’s heart is beating and then weigh the mother. In addition, we inform her about what to do should complications arise,” Hem adds.
“They are really helpful,” says Lem. “I have received a lot of information from them, and I have decided to deliver at the commune health centre because it is much safer.”
Dealing with complications
Three weeks ago Hem, the village-based midwife, received a call from another pregnant women in the village, Chamalea Thi Lum, who was going into labour. “When I arrived at her house I realized that her blood pressure was very low,” recalls Hem. “I knew about her case because Lum had gone to the commune health centre for check ups. Her baby’s head was up. I identified the complication and took her to the commune health centre, where she was attended by Loan, the midwife, while I assisted. As it was midnight we could not find a car to get to the district hospital, but Loan assessed the situation and felt confident enough to go ahead with the delivery. It took a very long time for the mother to deliver, but luckily we managed to have a successful delivery,” Hem explains with relief.
Policies to support the new practice
To optimize the effectiveness of this ethnic minority midwife model, supportive policies are needed. A policy framework for ethnic minority midwives within the national health system has yet to be established so the UN is working with the Ministry of Health (MOH) on this. At the same time, the Training and Science Department of the MOH is working to include the ethnic midwife training model in the regular curriculum at secondary medical schools while the Department of Human Resources is revising the MOH salary scale to include their wages.
“The UN has been advocating for ethnic minority midwives to be recognized as one of the most valuable resources for mountainous areas, since we believe they play a key role in improving maternal health,” says Bruce Campbell, the UNFPA Representative in Viet Nam. The progress made towards the official utilization of village-based ethnic midwives by the health system and the decision to strengthen the contingent of midwives in ethnic minority areas are reflected in the new National Strategy on Population and Reproductive Health, which is currently being developed. In addition, the agreement to consider the role of ethnic midwives in the national Joint Annual Health Review 2010, developed by the MOH and the Health Partnership Group (which includes development partners and stakeholders in the health sector of Viet Nam), demonstrates that all these efforts are beginning to bear fruit.