Reducing maternal mortality is a complex undertaking, and the Northern mountains of Viet Nam, where communities of ethnic minorities live in remote villages, pose particular problems. Maternal mortality ratio in this region is 411 deaths per 100,000 live births, and most women deliver at home without skilled attendance.
HA GIANG TOWN, Viet Nam — Long distances, poor roads, poverty and traditional customs for dealing with pregnancy and delivery are factors that lead to many home deliveries in this mountainous region. As a way to protect the health of pregnant women and newborns, UNFPA, the United Nations Population Fund, has initiated a pilot project for recruiting and training local women to become midwives.
Fourteen recent graduates will soon be returning to their villages to provide family planning advice, pre- and post-natal care, attend routine deliveries and make sure that women get higher levels of care should complications arise. UNFPA also supports the provision of mobile emergency obstetric and newborn services in four districts by providing medical equipment, ambulances and essential drugs to the district hospital and the Commune Health Stations.
Bordering China, Ha Giang is sparsely populated -- 724,353 inhabitants spread out over an area of almost 8,000 square kilometres– with many villages perched on hard-to-reach mountainsides. One of the poorest provinces in the country, Ha Giang is overwhelmingly (90 per cent) comprised of ethnic minority groups, including H’Mong, Tai, Giay, Nung and Clao peoples, as verified in a recent census. The strategy underlying the pilot project is that health care workers who understand their language and their belief systems can inspire trust and encourage more women to receive appropriate services.
Cultural sensitivity is key
For Dam Van Bong, Vice Chairman of Ha Giang’s People’s Committee, recruiting and training midwives locally is extremely appropriate for this province. “Participants were selected among different ethnic minority groups, so they speak the same language as their villagers,” he said. “They know the families living in the villages and can easily approach women to provide counselling and services. This is crucial to overcome the cultural barrier and offer safe motherhood services,” he added.
Recruiting locally is key, because after the training, graduates are expected to return to their communities to serve as health workers and midwives. “If we trained people from other provinces in order for them to work in remote areas, they would give up,” explained Phung Thi Duyen, provincial trainer who supervised the midwives during their practice at the hospital.
Hands-on training approach
The 18-month training was divided into four modules, combining theory and practice in health facilities. “The training method was learning by doing, with trainers coaching participants very closely and mentoring them throughout the whole process,” said Nguyen Van Qui, director of the Department of Health. At the completion of the course, all fourteen participants received two certificates that qualify them to perform as village health workers and village-based skilled birth attendants, guiding people on hygiene for disease prevention, first aid, care for common diseases and safe motherhood.
“I saw the trainees in the hospital and they have learnt a lot. Their technique is quite good. Just to give some examples, they can provide maternal health and family planning counseling and they know how to be prepared for and attend normal delivery cases in a safe way. Besides, these ethnic midwives have been trained to identify complicated cases and refer them to higher levels,” said Duyen.
Overcoming personal challenges
The participants, who were aged from 18 to 30 years old, went on this adventure leaving behind their villages and families. During the training, they stayed in a house in Ha Giang Town, close to the hospital, where the training took place. In some cases, this was the toughest part. “It was especially difficult for me because I gave birth to my son only two months before the training started and I brought the baby with me. I had to look for a babysitter to take care of him while I was at the training”, explained Van Thi May, one of the recent graduates
Despite all this, the experience was worthwhile. “I had no knowledge about health before, but now I know how to take care of pregnant women. I hope I can keep on supporting them when I go back to my village. I will do my best so that people listen to me, change their behavior and seek medical advice during pregnancy,” said May.
To optimize the effectiveness of the intervention, a strong commitment and support is required from the authorities, the health system and the whole community. In addition to the Department of Health’s decision to recruit these trained midwives to work in the system as village health workers, political commitment also means allocating funds from the provincial budget to pay their monthly wages. This seems likely to happen. The Vice Chairman of Ha Giang’s People’s Committee, Dam Van Bong, has already confirmed that government budget will be used to open a new training course in the second quarter of this year with technical support from UNFPA and other donors. Finally, regular technical backstopping should be provided to these midwives to ensure a good performance.
On the other hand, a policy framework for ethnic midwives to be officially utilized by the health system has yet to be designed and set up. In this regard, and to make it possible, Nghiem Thi Xuan Hanh, an expert of the Maternal and Child Health Department, said that the Ministry of Health is currently reviewing related-training documents and the code for civil servants. “As a next step, the Department of Human Resources will revise the salary scale of the Ministry of Health to include ethnic midwives wages.” At the same time, the Training and Science Department is working to include this training model into the regular curriculum at secondary medical schools. All these actions will contribute to keeping skilled health personnel working in mountainous and ethnic areas and to establish a process that can be replicated in other provinces.
— Maria Larrinaga