Gender Inequalities and Maternal Health Care
Although maternal health care has been improved in the last decades, the achievement of millennium development goal 5 (MDG5) to reduce maternal mortality by 2015 by three-quarters from the level of 1990 is still far off the track in most countries of the world.1 Countries that have actually succeeded in improving maternal health and reducing maternal mortality are still facing big inequalities between different segments of the populations.2 Disadvantaged groups of women tend to have higher rates of both maternal morbidity and mortality and inadequate access to safe, affordable, and acceptable maternal and child health care.1 , 2
Gender is a strong determinant of most health outcomes, including maternal and child health.3 , 4 It is the idea and situation that women and men are not equal, referring to unequal treatment or perceptions of individuals due to their gender.5 Gender inequalities are identified as associating significantly with women's utilization of some types of maternal health services, that is, having at least 4 antenatal care visits (ANC4+), giving births with skilled attendance, and using contraceptive methods in low- and middle-income countries such as India, Bangladesh, and Tanzania.6–9 Furthermore, the Commission on Sociodemographic Determinants of Health has developed a conceptual framework for action on the sociodemographic determinants of health.3 The framework presents structural and intermediate determinant factors that contributed to inequitable distribution of health and diseases across social groups.3 The sociodemographic determinants of maternal health care utilization for disadvantaged groups have been identified.10–13 These include disparities with regard to gender, parity, household incomes, education, out-of-pocket payment, place of residence, and ethnicity. Important intermediary factors generating inequality in the utilization of maternal health services, for example, include less educated, ethnic minority women living in rural, poor regions. Among all the determinants, gender inequalities are increasingly recognized as the most important determinant of health for women.3
Gender Inequalities and Women's Utilization of Maternal Health Services in Vietnam
The goal of gender equality has been repeatedly considered as a priority in Vietnam's national agenda since 1946 and strides have been made over the last decades. To date, Vietnam is far ahead of most other countries with similar levels of income in terms of human development and gender equality. The Vietnamese adult female literacy rate, for example, is relatively high (94.8%)14 and women's participation in the labor force is substantial (48.7% of women 15 years of age or older by 2014).15 Gender inequalities, however, are still deep rooted in Vietnam. Influenced by Confucianism, especially in the Northern parts, son preference is strong in this culture. Reasons for this preference include notions that sons can inherit the family resources and preserve the family line in the future.12 , 16 This tradition has implications for an imbalance in sex ratio at birth, unnecessary delays and underuse of health services by women, domestic violence, and low contraceptive use. Furthermore, the health system is faced with providing more culturally sensitive and right-based approaches to gender equity in delivery of maternal health services.4 Therefore, there is an urgent need to implement efforts, such as empowering women via a set of gender measures and enhancing political will17 to improve gender equality and thus promote maternal health care in Vietnam.
The association of sociodemographic determinants and maternal health care utilization has been discovered in Vietnam.18 The ethnicity, household wealth, and education are all significantly associated with antenatal care coverage and skilled birth attendance. The ethnicity is highlighted as having significant effect over household wealth and education. Mothers from poor households who are ethnic minorities are 3-fold less likely to attend any antenatal care and 6 times less likely to give births without skilled attendance.18 Birth rate at home among ethnic minority women, a majority of whom reside in rural areas, increased from nearly 5 times by 2006 to nearly 20 times by 2011.19 There has, however, been little research in Vietnam exploring the relationship between gender inequalities (control over earnings, decision-making autonomy, the dynamics of the relationship between a woman and her partner, and domestic violence) and maternal health care utilization. The goal of this study, therefore, aimed to explore the association between gender inequalities and utilization of maternal health services in Vietnam.
Study setting and population
A cross-sectional household survey was conducted in South Central Coast region in Vietnam during August 2013 to May 2014. The South Central Coast region encompasses a combination of 8 mountainous and coastal provinces. Out of the total population of 8.93 million, a majority of Vietnamese (Kinh) people live in the mainland, while most of the minority ethnic groups live in the mountainous part.14
Two districts in each province representing the coastal and mountainous districts were purposively selected (n = 16). In each district, 2 communes were randomly selected (n = 32). The target population included all mothers who delivered a year prior to the date of interview. About 30 women who delivered a year prior to the date of interview were systematically selected in each commune on the basis of the lists provided by commune health centers. A total of 907 respondents participated in this study. This indicated a 5% refusal rate as our sampling size was 960.
This study included 3 outcome variables according to the 4 criteria of the National Strategy on Gender Equality for the 2011-2020 Period 20 as following:
Number of antenatal visits: Women were asked how many times they had antenatal examinations during their last pregnant period. The answers were then categorized to “4 or more antenatal visits” and “less than 4 antenatal visits.” ANC4+ was defined as those who reported to have 4 or more antenatal visits during their last pregnant period.
Institutional delivery was defined from the answer of women who reported to deliver their last child in a health facility.
Ever used a contraceptive method was defined from the answer of women who reported to have ever used a contraceptive method.
We selected and evaluated 8 potential sociodemographic variables (age, ethnicity, residency, education, occupation, household income, distance to commune health center, and health insurance) relating to the 3 outcome variables. Age was categorized into 3 age groups of less than 19 years, 20 to 34 years, and more than 35 years. Ethnicity was dichotomized into majority groups (who are the Kinh people) and minority groups (all remaining ethnic groups). Residency was divided into 2 groups: Coastal and mountainous. Education was divided into 2 levels of education: Secondary school and less and high school and higher. Current occupation comprised 3 groups: Informal work (farmer, housework, and craft worker), government officials (being employed as government officials), and owner business. Household income was dichotomized into poor and near poor (households who earn less than US $60 per person per month as suggested by World Bank) and middle or higher income (households who earn more than US $60 per person per month). Distance to commune health center included 2 categories: Less than 5 km and 5 km and greater. Finally, health insurance was divided as Yes (having health insurance) and No (not having health insurance).
Furthermore, gender inequality variables were composed of 6 dichotomous variables with only 2 values as Yes and No as following: Earning equal income to husband, perceiving equal role in decision making, perceiving equal role in deciding maternal care, discussing maternal care with husband, experiencing domestic violence, and having a strong preference for son.
Semistructured questionnaires were used to gather data from women who delivered a year prior to the date of interview. The data were to identify the coverage of maternal health services and their associated factors of sociodemographic characteristics, sociodemographic determinants, and gender equality measures.
During 3 months (September to November) in 2014, trained interviewers (researchers from Hanoi School of Public Health) visited households and administered questionnaires in all 8 provinces. If selected mother could not speak Vietnamese, a village health worker helped translate for the interviewers.
Data were entered using EPIDATA and double-checked before analyzing using Stata 13. The data were clustered by the survey design, that is, by district and by commune before performing any analysis. Since we have a small rate of missing values (<5% in all variables), we excluded these from bivariate and multiple logistic regression. A purposive selection process for multiple logistic regression model begins by a bivariate analysis with all potential independent variables. The dependent variable was women's utilization of maternal health services (ANC4+, institutional delivery, and ever used a contraceptive method). The independent variables were sociodemographic, social determinant, and gender equality measures. The multiple logistic regression (using stepwise method with backward elimination) was applied for variables with statistical significance in the bivariate analysis with the outcome variables. We removed variables from the multiple logistic regression model if they were nonsignificant, highly correlated to each other, and/or not a potential confounder. The final variables after elimination from the multiple logistic regression model, that is, significant covariates and confounders, were factors associated with access to and utilization of maternal services. Confidence interval of 95% (95% CI) was calculated and P value of less than .05 was considered statistically significant.
Ethical clearance was obtained from the institutional review board of Hanoi School of Public Health. Ethical guidelines were followed and participants were recruited after obtaining informed written consent.
Sociodemographic characteristics of participants
A total of 907 mothers with children younger than 1 year participated in the study (Table 1). The women were similar with regard to residency proportions but not age (a majority aged between 20 and 34 years), ethnicity (two-thirds were ethnic majority group), education (two-thirds had secondary or higher education), and occupation (most had informal work, that is, housework or self-employed). Less than half of the respondents were poor and near poor, most lived within an area of less than 5 km to closest commune health center, and a majority had health insurance.
A majority of women (82%) had lower income than their husbands and two-thirds (67%) perceived unequal role in decision making. Although two-thirds of women (63%) thought that wives and their husbands were equal in deciding maternal care, there was almost no discussion between husbands and wives regarding maternal health care (18%). Finally, about one-sixth (16%) reported that they experienced some form of domestic violence and a similar proportion had a strong preference for a son.
Utilization of maternal health services
Tables 1 and 2 depict results from the bivariate model and multiple logistic regression model between dependent variables (have fourth or more antenatal care visit (ANC4+), institutional delivery, and ever use of contraceptive method) and independent variables. The logistic multiple with adjusted for all factors in the final model shows the association of independent variables and the outcomes (Table 2). Ethnicity, residency, occupation, and household income had significant association with the utilization of some types of maternal health services (P < .05). With regard to gender equality measures, having equal income to husband and discussing maternal care with husband were significantly associated with utilization of some types of maternal health services.
More than half of the women had ANC4+ (54%) (Table 1). Four variables that were significantly associated with having ANC4+ were ethnicity, occupation, household income, and discussing maternal care with husband (P < .05) (Table 2). Ethnic majority women were 2 times more likely to have ANC4+ than ethnic minority women (adjusted odds ratio [aOR] = 2.1, 95% CI: 1.4-3.4). Women having formal job (business owners or government officials) were 2 to 3 times more likely to have ANC4+ than those having an informal job. Women in middle- and high-income groups were 2.3 times more likely to have ANC4+ than those in poor and near poor groups (aOR = 2.3, 95% CI: 1.6-3.2). Women who discussed maternal care with their husbands were also 1.5 times more likely to have ANC4+ than those who did not (aOR = 1.5, 95% CI: 1.0-2.4).
A majority of women (96.7%) delivered in a health facility in their last childbirth (Table 1). Only ethnicity had significant association with institutional delivery in the final model (P < .05) (Table 2).
Ever used a contraceptive method
Of 907 respondents, about two-thirds (69.8%) had ever used a contraceptive method (Table 1). Five variables had significant association with ever used a contraceptive method, that is, ethnicity, residency, occupation, earning equal income to husband, and discussing maternal care with husband (P < .05) (Table 2). Ethnic majority women were 2 times more likely to ever use a contraceptive method than ethnic minority women (aOR = 2.2, 95% CI: 1.0-4.8). Women living in mountainous areas were 2 times more likely to use a contraceptive method than those living in coastal areas (aOR = 2.1, 95% CI: 1.1-4.3). Women who had a formal job (government officials or business owners) were 1.3 to 4.1 times more likely to ever use a contraceptive method than those having an informal job. Notably, women who had equal income to their husbands or discussed maternal services with their husbands were 2 times more likely to use a contraceptive method than those who did not (aOR = 2.1-2.6).
This study explored how gender inequalities and sociodemographic determinants of health associated with women's utilization of maternal health services. Compared with the national level, women in 8 South Central Coast provinces had a lower rate of utilization of ANC4+ (53.9%)21 but similar institutional delivery rate (97%) and ever used a contraceptive method (69.8%).22 Two gender equality variables (discussing maternal care with husband and having equal income to husband) and 4 sociodemographic determinants of health (ethnicity, residency, occupation, and household income) had significant association with utilization of maternal health services.
Although Vietnam succeeded the Millennium Development Goal (MDG3) and MDG5 on the national level, maternal health care is still faced with big inequalities between different segments of the populations. In our study, ethnic majority women (ethnicity), women living in urban areas (residency), women with noninformal work (occupation), and women with better off economic conditions (household income) were more likely to use maternal health services. Consistent with our findings, women in rural areas, for example, are less likely to use health care services than those in urban areas in many low- and middle-income countries, including Vietnam, India, and China.7 , 13 , 23 Women with higher socioeconomic conditions are more likely to recognize the risks of pregnancy and thus, often seek maternal health care earlier.24 , 25
Health insurance, however, did not associate with the utilization of any types of maternal health services in our study although a majority of respondents had health insurance. One possible explanation could be the bureaucratic obstacles, low reimbursement rates, and poor service quality for health insurance users.26 As a result, poor women in rural areas and having lower income tend to use more private maternal health services despite higher average fees than those in the public sector.27 This, unfortunately, broadens the utilization gaps of maternal health services, especially among the poor and ethnic minority women in rural areas.28
There is, to the best of our knowledge, little research about the relative importance of these different sociodemographic determinants of health and their potential synergy effects on maternal health services in Vietnam.18 Ethnic minority women tend to live in rural areas, have lower education,14 are poorer, have informal work,29 and have less knowledge about maternal health care19 than ethnic majority women in urban areas. In our study, ethnicity was the only variable associated with the utilization of all 3 types of maternal health services. This implied a significant effect of ethnicity over and above other sociodemographic determinants (residency, household income, and occupation). This finding is consistent with other studies, whereas ethnicity is the most important sociodemographic determinant for antenatal care and skilled birth attendance in Vietnam.19 , 30 The use of maternal health care has improved overall in the population, but the disparity of use among the ethnic minority and majority population is growing.18 , 31 Ethnic minority women have many barriers when seeking maternal health services, including cultural beliefs, costs, and inappropriate services at health facilities.12 Although there are policies to support health delivery in the most difficult districts and communes, many challenges on accessibility and acceptability of services are still reported.31 These include low health insurance coverage,28 dissatisfaction due to the bad attitudes and services from health staff,32 , 33 lack of culturally adapted services,19 differences in language, government decentralization policy, and growing private health sector.29 These have important implications for the health system to provide services that should take into account this disadvantaged group.
Our study also highlighted that women, who had an equal role within the context of their daily life and relations with their husbands, had higher access to and utilization of maternal health services. Our findings are consistent with other studies in low- and middle-income countries such as Nepal, Nigeria, Malawi, and Sub-Saharan countries.34–39 Women who have better socioeconomic status and financial autonomy within their households feel at ease to decide and seek for health care.40 Similarly, couple discussion could increase women's knowledge and decrease male opposition, which, in turn, raises women's confidence to make decisions regarding their health care.41 Joint decision making between husbands and wives yields better reproductive health outcomes than women making decisions without input or agreement from their partners.41 In Bangladesh, the husband-only decision making is negatively associated with antenatal care use and skilled delivery care.42 In contrast, in Nepal, the husbands are increasingly entering into the area of maternal health, which was traditionally considered as “women business.”37 In Vietnam, wives with the husband's involvement in family planning are more likely to use contraceptives.43 However, findings are very much depending on types of service utilized.42
The involvement of men is complex and shaped by many factors, including their availability, cultural beliefs, and traditions.34–39 In Vietnam, there is a traditional belief that the pregnancy and childbirth are the women's domain, and men's main responsibility is to provide the funds. Sharing the responsibilities between couples (couple discussion), therefore, needs to be a focus for future interventions and programs on maternal health care improvements.
This study was conducted with a large sample size, which was adequate to gain general estimates of having ANC4+ visits and its associated factors. With a cluster sampling strategy for data collection in 8 southern coastal provinces, the studied subjects were expected to be reasonably representative of not only the southern coastal region but also rural areas in Vietnam. All associated factors were taken in compliance with the theoretical framework.
This study also has limitations. The data were collected by interviewing mothers who delivered within 1 year, which could be prone to recall biases. Some of the ethnic minority respondents, Vietnamese, may not fully understand some of the questions. There could have been some socially desirable responses, especially questions related to the equality in decision-making and sex equality. To accommodate this, interviews were conducted confidentially, in the absence of spouses, to avoid biased responses. Due to the low number of participants who were not institutional delivery, our analysis could not detect any significant association between independent variables and institutional delivery. This limited the multiple analysis for determinant factors that related to institutional delivery.
This study explored the association between sociodemographic determinants of health and gender inequalities with utilization of maternal health services in 8 coastal provinces of Vietnam. Women's equal role within context of their daily life and relations with their husbands (discussing maternal care with husband and having equal income to husband) supported their use of maternal health services. Among all associated variables, ethnicity was the only determinant, which associated with the utilization of all maternal health services. The remaining variables, occupation, income, and residence, associated to 1 or 2 types of maternal health services. Discussing maternal care with husband and equal income to husband were found to be more important than other sociodemographic determinants.
Our findings suggested the implementation of concerted efforts from all relevant stakeholders to consider the disadvantaged women in planning and delivery of maternal health services, especially ethnic minorities. Furthermore, the health system should improve male involvement strategies to promote maternal health care, especially during prenatal and postpartum periods.
Implications for Policy & Practice
- Maternal health services should prioritize to deliver more culturally sensitive and right-based maternal care to disadvantaged women.
- Men are needed to be engaged in service delivery to adapt and ensure the most appropriate and effective maternal health care.
- Gender-responsive maternal health policies that support and favor women and girls are also needed to be put in place.
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