Reproductive outcomes in rural Vietnam. Perspectives and experiences by pregnant women and health care professionals on pregnancy promotion and maternal health care

Sammanfattning: Background Reproductive health and health events associated with pregnancy including induced abortions are among the most important factors for the health of fertile women. Adverse outcomes have an impact on women’s reproductive health and their overall health as well as the health of their offspring. Pregnancy and child bearing take place within a cultural context. Risk factors for adverse pregnancy outcomes depend on factors both associated with the individual woman as well as contextual factors.Aims This thesis investigates reproductive health indicators and their determinants for women in a rural district in Vietnam with special focus on adverse pregnancy outcomes and their determinants. In addition, this thesis explores the perspectives and experiences among pregnant women and health care professionals on maternal health care in Vietnam and risks during pregnancy and delivery.Methods The studies used quantitative and qualitative methods.  In the quantitative studies a total of 4,396 women reporting 5,838 pregnancies, and 5,521 infants were included. Parametric and non parametric tests and univariate and multivariate logistic regression analysis was performed.   For the estimation of small for gestational age a population-specific reference curve was constructed based on the mean birth weight at term in the study population. In the qualitative studies data were collected from eight focus group discussions, four with pregnant women and four with health care professionals. Manifest and latent content analysis was applied. Main findings Women belonging to an ethnic minority or women giving birth at home were at increased risk of stillbirth.  The risk of induced abortion increased with maternal age. Neonatal mortality was estimated to 11.6 per 1000 live births and perinatal mortality to 25.0 per 1000 births. The prevalence of small for gestational age was estimated to 6.4%. Risk factors for small for gestational age included women in farming occupations and post-term birth. There was a marked decrease in perinatal mortality after 33 weeks of gestation.Contextual conditions influenced both pregnant women’s use of maternal health care and the performance of the health care professionals. The use of maternal health care was influenced by economical conditions as well as cultural norms that impeded women’s autonomy. Structural constraints included inadequate financing of the health system, including lack of staff, insufficient professional re-training, and inadequate equipment. Pregnant women in rural Vietnam created a strategy to promote a healthy pregnancy through lifestyle adjustments, gathering of information, and seeking timely medical care. Insights in pregnancy-related conditions were sought from various sources and were influenced both by Vietnamese traditions and modern medical knowledge.Conclusions Knowledge about pregnancy complications and their related signs and symptoms, and a high confidence in the maternal health care probably contribute to the relatively good maternal health status and pregnancy outcomes in Vietnam. To improve perinatal and neonatal outcomes there is a need to ensure access for all pregnant women to delivery units with surgical capacity in case of an obstetrical emergency. Also, a higher proportion of premature infants need to be born at units with access to neonatal care. This may be achieved by an improved system for referral including capacity of medical care during transportation. Other desirable improvements include antenatal identification of small for gestational age foetuses. In our study the induced abortion rate increased with maternal age and was highest among married women, indicating that induced abortions may be used as a method for family planning.The cultural norms in Vietnam limit women’s autonomy and reduce their possibility to make independent decisions about their reproductive health. Our studies emphasize the importance of adequate access for all women to maternal health care adjusted for their individual needs. A better understanding is needed of context-specific factors that influence couples’ choice of family planning methods, place of birth, and maternal health care. The communication between pregnant women and health care professionals needs further investigation. This knowledge is essential in order to develop reproductive health services that are accessible, acceptable and affordable to all.