Deconstructing ‘barriers’ to access Minority ethnic women and medicalised maternal health services in Vietnam

This art icle was downloaded by: [ 81.84.120.101] On: 03 February 2013, At : 09: 42 Publisher: Rout ledge I nform a Lt d Regist ered in England and Wales Regist ered Num ber: 1072954 Regist ered office: Mort im er House, 37- 41 Mort im er St reet , London W1T 3JH, UK Global Public Health: An International Journal for Research, Policy and Practice Publicat ion det ails, including inst ruct ions f or aut hors and subscript ion inf ormat ion: ht t p: / / www t andf online com/ loi/ rgph20 Deconstructing ‘ barriers’ to access: Minority ethnic women and medicalised maternal health services in Vietnam Joanna Whit e a , Pauline Oost erhof f b & Nguyen Thi Huong c a Cent re f or Research in Ant hropology (CRIA-IUL), Inst it ut o Universit ário de Lisboa, Lisbon, Port ugal b Royal Tropical Inst it ut e, Amst erdam, The Net herlands c Harvard Medical School AIDS Init iat ive in Viet nam, Hanoi, Viet nam Version of record f irst published: 17 May 2012 To cite this article: Joanna Whit e , Pauline Oost erhof f & Nguyen Thi Huong (2012): Deconst ruct ing ‘ barriers’ t o access: Minorit y et hnic women and medicalised mat ernal healt h services in Viet nam, Global Public Healt h: An Int ernat ional Journal f or Research, Policy and Pract ice, 7: 8, 869-881 To link to this article: ht t p: / / dx doi org/ 10 1080/ 17441692 2012 679743 PLEASE SCROLL DOWN FOR ARTI CLE Full t erm s and condit ions of use: ht t p: / / www.t andfonline.com / page/ t erm s- andcondit ions This art icle m ay be used for research, t eaching, and privat e st udy purposes Any subst ant ial or syst em at ic reproduct ion, redist ribut ion, reselling, loan, sub- licensing, syst em at ic supply, or dist ribut ion in any form t o anyone is expressly forbidden The publisher does not give any warrant y express or im plied or m ake any represent at ion t hat t he cont ent s will be com plet e or accurat e or up t o dat e The accuracy of any inst ruct ions, form ulae, and drug doses should be independent ly verified wit h prim ary sources The publisher shall not be liable for any loss, act ions, claim s, proceedings, dem and, or cost s or dam ages what soever or howsoever caused arising direct ly or indirect ly in connect ion wit h or arising out of t he use of t his m at erial Global Public Health Vol 7, No 8, September 2012, 869Á881 Deconstructing ‘barriers’ to access: Minority ethnic women and medicalised maternal health services in Vietnam Joanna Whitea*, Pauline Oosterhoffb and Nguyen Thi Huongc a Centre for Research in Anthropology (CRIA-IUL), Instituto Universita´rio de Lisboa, Lisbon, Portugal; bRoyal Tropical Institute, Amsterdam, The Netherlands; cHarvard Medical School AIDS Initiative in Vietnam, Hanoi, Vietnam Downloaded by [81.84.120.101] at 09:42 03 February 2013 (Received 20 June 2011; final version received 30 January 2012) Low maternal health service utilisation amongst minority ethnic women in Vietnam is often attributed to ‘traditional customs’ Drawing on secondary data and original, qualitative research amongst Hmong and Thai communities, this paper analyses minority behaviour related to childbirth The informed selectivity in service attendance identified can be considered, in part, a rejection of current medicalised approaches at health facilities, where supine delivery is compulsory and family members are prohibited from attending women in labour The paper reveals how conventional analyses of barriers to minority maternal health service utilisation inhibit scrutiny of the ways services fail to engage with or accommodate local preferences Participatory identification of mutually acceptable delivery methods by maternal health staff and local women is recommended to enable the development of culturally inclusive services Keywords: minority ethnic groups; childbirth; Vietnam; culture; medicalisation Introduction Increasing medicalisation of childbirth is a worldwide trend (Buekens 2001, De Brouwere and Van Lerberghe 2001, Van Teijlingen et al 2004, Lumbiganon et al 2010) Yet, user responses to medicalised services range from compliance to resistance and indifference, and are often based on pragmatic calculations as to how interventions might enhance (or not) women’s lives (Lock and Kaufert 1998, Oosterhoff et al 2008) Maternal health-seeking behaviour is rarely an individual matter; practices pertaining to pregnancy and childbirth are influenced by the families and communities to which women belong and the socio-cultural institutions with which they engage (Jordan 1997, Lock and Kaufert 1998) Maternal health services in Vietnam Vietnam’s transition to a modern state with a market-oriented economy, which commenced in 1986, involved several phases of health service reform The socialist preventive model was replaced with western-oriented public health training, and increasingly technological approaches (Tuan 2004) While national-level health indicators have improved (United Nations [UN] 2008), Vietnam now has one of *Corresponding author Email: jowhite67@yahoo.co.uk ISSN 1744-1692 print/ISSN 1744-1706 online # 2012 Taylor & Francis http://dx.doi.org/10.1080/17441692.2012.679743 http://www.tandfonline.com 870 J White et al Downloaded by [81.84.120.101] at 09:42 03 February 2013 the highest rates of caesarean section in Asia The particular application of new maternal health technology is significant Ultrasound and prenatal screening now proliferate in urban areas (Gammeltoft and Nguyen 2007, Oosterhoff et al 2008), for instance, and pregnancy is increasingly understood by the majority ethnic Kinh population as a medical condition requiring technical surveillance (World Health Organization [WHO] 2003) The National Standard Guidelines on Reproductive Health define the delivery position as ‘lying on the back’ (Ministry of Health [MOH] 2009); standard practice at all health facilities is for the parturient to recline on a delivery bench with her legs in stirrups, attended solely by medical staff Yet, maternal health service attendance is inconsistent (United Nations Population Fund [UNFPA] 2007b), which has been attributed to a range of factors, including education, income, geographical isolation, perceptions of service quality and ethnicity (Duong et al 2004, Adams 2005, Trinh et al 2007) Minority utilisation of maternal services: limitations of current understanding Vietnam is home to 53 diverse minority ethnic groups, many of whom inhabit rural, mountainous areas and live in relative poverty (McElwee 2008, World Bank 2009) Prohibitive cost is no longer understood to be a significant obstacle to minority access to health services due to various state measures, including the introduction of the nationwide Health Care Fund for the Poor, offering free healthcare through a designated ‘first-stop’ health post, normally the commune health centre (CHC), the facility most accessible to poor, rural communities (Axelson et al 2009) Yet, available data suggest that maternal health service utilisation by minority women remains especially low (WHO 2003, Sepehri et al 2008, UNFPA 2008b, UNICEF 2009) Furthermore, maternal mortality amongst minorities is understood to be relatively high Á four times higher than Kinh maternal mortality according to one recent estimate (WHO 2005) Á adding urgency to concerns about low attendance for ante-natal care (ANC) and delivery Yet, current understanding is based on scarce and often insufficient information: a recent situational analysis which reviewed all available studies on maternal mortality failed to distinguish ethnicity as a contributory factor due to data limitations (Knowles et al 2009) Furthermore, the various issues influencing maternal mortality are not disaggregated in current analyses, hence CHC staff skills, referral to adequate emergency services Á which can be problematic in mountainous areas Á as well as ‘local customs’ are conflated (see e.g UNFPA 2007b and UN Vietnam 2010) Limitations in current data underscore the need for greater research on minority maternal health-seeking behaviour Low service attendance is often ascribed to geographical remoteness (WHO 2003, UNFPA 2007b, Humphreys and Vu 2008) Yet, many CHCs are located within several kilometres of villages, and as many minority families routinely travel long distances to pursue their livelihoods, the concept of ‘remoteness’ is relative (UNFPA 2007a) Vaguely-defined ‘traditional customs’ are also regularly posited as a barrier to reproductive health service utilisation (Doan 2007, UNFPA 2007b, UNFPA 2008b) Such representation of minority cultural practices as obstacles to service attendance can be seen to conform to prevailing stereotypes within Vietnam regarding the ‘otherness’ and ‘backwardness’ of minorities inhabiting mountainous areas (Humphreys and Vu 2008, World Bank 2009, Nguyen 2010, Turner 2010) Similar depictions are common in Downloaded by [81.84.120.101] at 09:42 03 February 2013 Global Public Health 871 other South-east Asian settings which are home to minority populations, and are rarely challenged (Duncan 2008) As observed elsewhere in the region, this discourse inhibits reflexive examination of the nature and quality of maternal services, and whether these best serve minority users’ needs (WHO 2003, UNFPA 2008a) A preference for delivery environments not offered in state facilities has already been identified within certain communities (Humphreys and Vu 2008, Sepehri et al 2008) The fact that most health staff in Vietnam are Kinh and rarely speak local languages (Humphreys and Vu 2008, Sepehri et al 2008, Integrated Regional Information Networks [IRIN] 2009) and that stigmatisation of minority users by Kinh health staff (UNFPA 2008b) may also serve to discourage attendance Drawing on secondary data and original research conducted with Hmong and Thai communities in north-western Vietnam, this article explores current minority practices and utilisation of services pertaining to maternity Primary data were collected through a prevention of mother-to-child transmission (PMTCT) of HIV programme During a 2008 assessment conducted by the programme in Dien Bien and Ha Giang, provinces with large minority populations, government staff expressed concern about poor maternal health service uptake, attributing this to poor education, physical remoteness and minority ‘traditions’ The study was therefore devised to enhance understanding of childbirth practices and maternal health-seeking behaviour among local Thai and Hmong villagers Methods Secondary data were gathered through a literature review of published material and unpublished reports produced by international agencies Two studies were then conducted by a team of eight female researchers in Ha Giang and Dien Bien between March and June 2010 Ethical approval was obtained from the commissions of scientific research within the relevant provincial departments of health.1 The studies conformed to universal ethical principles and followed a similar methodology Several neighbouring communities, situated close to health facilities, were selected, so that geographical distance was unlikely to be a factor influencing service attendance For the Hmong study, two communities were chosen from the same commune in a remote district of Ha Giang bordering China Village A was located immediately next to the CHC, which was established in 2000 and Village B was situated 1Á2 km from this facility The district hospital was 1Á2 km from Village A and 0.5Á1 km from Village B Research with the Thai took place in three villages in the same commune in Dien Bien: two long-standing Thai communities (Villages C and D) and one Kinh village which became predominantly Thai over recent decades due to land transactions (Village E) All three communities were situated less than km from the local CHC, which was established in 1995, and km from the district hospital In-depth interviews were conducted to gain insight into experiences and decisionmaking pertaining to childbirth; questions were focused particularly on the most recent delivery The interviews were structured around an open-ended questionnaire Interviewees were selected according to a random, proportional, age-stratified sample of women of reproductive age (15Á49 years) who had delivered at least one child, using village population lists A total of 56 Hmong and 87 Thai women were interviewed (Table 1) To provide broader understanding of traditional practices 872 J White et al Table Study sample (n 0179) Downloaded by [81.84.120.101] at 09:42 03 February 2013 Hmong (n 072) Village A Village B Total Thai (n 0107) Village C Village D Village E Total Interviewees FGD participants 29 27 56 8 16 30 31 26 87 7 20 related to pregnancy and childbirth and explore inter-generational differences, focus group discussions (FGDs) were held with women from different age groups randomly selected from village lists, excluding those selected for interview A total of five FGDs were consequently conducted with 36 women (Table 1) The discussions followed thematic guidelines Study participants provided informed consent, and received a small remuneration for their time The research team was trained in interview techniques and FGD facilitation, and all study tools were pre-tested and refined prior to fieldwork Given language barriers, Hmong and Thai women from outside the study communities were hired as interpreters These individuals were trained in elementary research methods All data were transcribed, translated into English and analysed according to a content analysis approach Initial analysis was guided by the thematic areas defined by the interview structures and FGD guidelines, while a second stage identified sub-themes, as well as variant views Some descriptive analysis of quantifiable data was conducted to contextualise findings The study has several limitations Studying minority communities in Vietnam can be difficult due to political sensitivities, and the research process is often closely controlled by government (Turner 2010) The fieldwork team benefited from the long-term relationship between the Vietnamese Government and the PMTCT programme; local state health providers facilitated access to communities However, using government staff as gatekeepers may have created biases in how the researchers were perceived Furthermore, the study took place over a short space of time within five distinct villages and cannot claim to represent the situation amongst wider Thai and Hmong communities Hmong childbirth as reported in secondary literature Hmong people first moved from Southern China to South-east Asian countries including Thailand, Myanmar and Vietnam during the eighteenth and nineteenth century The Hmong are understood to be among the least assimilated, most impoverished ethnic group in the Northern Mountains region of Vietnam, due to their relatively recent arrival and settlement in marginal lands The current Hmong population stands at over 787,000, around 1% of the total Vietnamese population (World Bank 2009) Hmong poverty rates rank among the highest in the country, at just under 90% (World Bank 2009).2 Education levels are the lowest of all ethnic Downloaded by [81.84.120.101] at 09:42 03 February 2013 Global Public Health 873 groups, with Hmong female access to education particularly limited (Baulch et al 2004, World Bank 2009) The health status of the Hmong is the lowest in Vietnam (WHO 2003) Published data on Hmong maternal health practices from Vietnam, or indeed wider South-east Asia, were found to be scarce, the exception being a recent ethnographic study from Thailand In this analysis, the role of the Hmong family house as a site for ancestral and other spiritual activities associated with delivery is emphasised Hmong women are described as remaining clothed during childbirth, and delivering in a squatting or sitting position at home Childbirth is presented as a largely female domain, with the father of the newborn responsible for ritual activities such as cutting the umbilical cord and burying the placenta inside the family house (Symonds 2004) Available literature on Hmong childbirth in Northern Vietnam similarly highlights the importance of ritual processes related to delivery and the dominance of home birth, although husbands are often reported as present during childbirth (Do 2002, UNFPA 2007a, UNFPA 2008b) Low rates of facility delivery are attributed variously, to geographical remoteness, men’s reluctance for their wives’ bodies to be examined by outsiders (and associated female ‘shyness’) and rituals which are better performed at home (UNFPA/PATH 2006, UNFPA 2007a, UNFPA 2008b) The centrality of customary practices in childbirth to the Hmong has prompted recommendations that health facilities are culturally adapted to attract local communities (UNFPA 2007a, UNFPA 2008b, IRIN 2009), although there is no evidence that this has occurred Childbirth amongst the Hmong in Meo Vac Á field study findings Focus group discussions conducted with the Hmong elicited a range of childbirth narratives It was common for women over the age of 60 years to have delivered without assistance from family members One elderly participant recounted: I came from the mountain when I had labour pains; no one was home I sat next to the bed to give birth and afterwards laid my child on the bed I took a string from the lining of my skirt and used it to cut the placenta I delivered four children on my own without any help.3 A culturally informed emphasis on silence and resilience, associated with rapid delivery outcome, was articulated by many of the older FGD participants, corresponding with details provided in secondary sources (Symonds 2004, UNFPA 2008b) Role of husband in delivery Elderly FGD participants contrasted how in the past women were more likely to deliver alone at home while the current generation prefers to have their husbands attending them; a cultural shift confirmed by younger participants One 41-year-old woman described the role of her husband during delivery: My husband was with me during my labour He hugged me until I delivered and made me feel less pain He held me in his arms until I finished giving birth afterwards he 874 J White et al cooked chicken and rice Several hours after the delivery he cooked egg soup with pepper for me.4 Downloaded by [81.84.120.101] at 09:42 03 February 2013 Points of consensus amongst FGD participants of all ages were the importance of sitting or squatting during labour, and the use of a low stool for this purpose Specific rituals associated with childbirth, such as the burial of the placenta, and the exercising of food taboos following delivery, were also detailed The frequency of home births within Hmong communities was confirmed and was attributed to the speed of delivery In the words of one participant, ‘I had a very quick delivery Á I had no time to go to the CHC’.5 The few FGD participants who had given birth at a health post remarked upon the difference between home and facility delivery One woman noted: When I was in the district hospital, they took care of my baby and me very well, but they did not allow my husband to be beside me This observation has added resonance if one considers the known limited Kinh language ability of most Hmong women, and hence their probable communication problems with health staff Several cases were described of CHC staff providing the family with the placenta for burial at home, but this appeared to be an informal, unsystematic arrangement Choice of delivery setting The predominance of home deliveries amongst the Hmong was confirmed by interview data Only a minority of respondents, of all ages, reported delivering their last child at a health facility (21/56; 37.5%).6 Yet, many more of the Hmong interviewees (37/56; 66%) had attended ANC at least once during their last pregnancy, highlighting a selective use of available services None of the home births reported were attended by health staff but in most cases women reported their husband being present (29/35; 83%) as well as other relatives or friends (28/35; 80%) A variety of perspectives regarding services were expressed by respondents within the same communities Of the women who reported attending a health facility to give birth, some attributed this either to a difficult delivery which had necessitated their being moved to a maternal health facility, others to their belief that a facility delivery would be safer, and others to the proximity of the health post Among those who had given birth at home, the most dominant explanation was the speed or the ease of the delivery Women’s shyness was rarely cited as an explanation Thai childbirth as reported in secondary literature The Thai (Tai) people inhabit areas of mainland South-east Asia, southern China and North-east India They are the third largest ethnic group in Vietnam, composing over 1.3 million people, around 1.7% of the total population (World Bank 2009) The Thai played an important role in Vietnam’s independence wars (Xiaobing 2010) and are understood to be economically integrated, while remaining culturally and socially separate (Baulch et al 2004, Trong 2007) Similar to the Downloaded by [81.84.120.101] at 09:42 03 February 2013 Global Public Health 875 Hmong, many Thai communities maintain strong ‘markers’ of their identity in terms of the decorative clothing and accessories worn by women, house structure, as well as traditional ritual and social practices (Oosterhoff et al 2011) Thai poverty rates stand at just under 60% (World Bank 2009) Thai net primary school enrolment rates are high, but secondary and higher education levels remain low (Humphreys and Vu 2008) Scholarly or other literature on Thai maternal health beliefs and practices are scarce The sole study identified details how childbirth usually takes place in a corner of the family house, normally close to the kitchen As is common in many South-east Asian cultures, the Thai place significant emphasis on women remaining warm or ‘cooking’ both during and following delivery, to restore equilibrium During the final stages of labour the pregnant woman kneels on the floor, both heels supporting her anus, while she holds onto a long, home-woven scarf (locally known as a pieu), suspended over a beam in the home Her husband physically supports her as she delivers, and she is also often attended by a traditional midwife and other family members or neighbours (Dai and Hinh 2006) Childbirth amongst the Thai in Dien Bien Á field study findings Thai FGD participants of all ages described traditional home delivery according to the process outlined above The communal nature of the enterprise was described: the delivering woman is held from behind as she holds the pieu, while another individual sits in front to help with the emerging newborn Participants emphasised the importance of the kneeling position, the aid provided by the pieu and the support of their husband in assisting them through the latter stages of labour As one 50-yearold woman described: We have more power when we hold the suspended cloth and squat and push The cloth swings from side to side and helps us to push more strongly A 49-year-old participant detailed: When we deliver, we press our heels into our anus, then we have more power to push the baby out our husbands support us from behind The importance of delivering close to a fire and keeping warm during and following delivery was also emphasised: We give birth close to the kitchen and afterwards we go into the kitchen to warm up we need to stay warm after delivering A number of FGD participants suggested a historical trajectory, whereby formerly, women delivered at home due to lack of services In the words of one 70-year-old woman: We give birth in the kneeling position But when we go to the clinic we have to lie down In the past, there was no CHC so we had to give birth at home, now we have the CHC so we go there to deliver 876 J White et al This statement can be interpreted as a public statement of knowing compliance with state desires (namely available services are attended if possible) As will be detailed below, interview findings challenge this representation, and it may be an important reminder of how problematic it is for minority women to criticise state services Other FGD participants distinguished delivery behaviour, however, depending on whether a labour was difficult or easy ‘If the labour is easy, it is still better to deliver at home’ commented one woman, while another observed ‘we only go to the CHC when we are having a difficult labour’ Some negative observations were made about the fact that husbands are not allowed to attend facility deliveries ‘It is just better if the husband is inside the room’, commented one 22-year-old participant Downloaded by [81.84.120.101] at 09:42 03 February 2013 Choice of delivery setting Interview findings confirmed the continuing importance of home birth The majority of interviewees (78/87; almost 90%) reported the family house as the location for their most recent delivery Similar to the Hmong, a certain selectivity in the use of services was identified; overall, just over half (50/87; 57.5%) of Thai study respondents attended ANC at least once during their most recent pregnancy Yet, of those who reported attending ANC during their last pregnancy, almost all (43/50; 86%) delivered at home While the majority of Thai interviewees reported being involved in the decision of where to deliver, some described how family discussions were held before a final decision was taken In some instances the discussion included not only the expectant couple but parents and parents-in-law, highlighting the importance of elder advice and how decision-making is rarely an individual matter The most commonly reported scenario was a discussion between a couple, as described by one respondent: I discussed things with my husband and we decided that if the delivery was easy I would deliver at home If the labour was difficult, I would go to the CHC Many interviewees presented home birth as a logical choice within their community, frequently providing the explanation ‘many women deliver at home’, a statement which reflects both the influence of the wider community and the deemed suitability of home birthing to women’s needs, at least in the case of non-problematic labour Local health facilities are used for emergency cases The few Thai interviewees who delivered at a facility attributed this to their labour being difficult or (less commonly) because they felt safer Yet local perspectives concerning health services were not uniform; several women who had delivered at home described their fear of giving birth at a facility One interviewee highlighted the absence of a regular electricity supply at the local CHC as a deterrent to attendance As already noted, the Thai place considerable importance on women staying warm during and following delivery, a scenario more easily afforded at home than in under-resourced local facilities Role of husband in delivery The vast majority of respondents whose most recent delivery was at home not only reported that female relatives were present during the birth (69/78; 88.5% Á in most Global Public Health 877 cases at least two other women), but that their husband also attended the delivery (61/78; 78%) A number of interviewees reported that their home birth was attended by a traditional practitioner (23/78; 29.5%), but this was not the dominant scenario Few of the many home deliveries reported were attended by health staff (3/78; 3.8%) The fact that husbands are not allowed to attend facility births caused concern, and even distress, to a number of interviewees who had experienced this prohibition Of those women whose most recent delivery had taken place at a health post, most reported that they and/or their husband had directly requested for him to be present at the delivery, but this was refused One 25-year-old respondent recounted her experience: Downloaded by [81.84.120.101] at 09:42 03 February 2013 My husband asked to stay but the health staff didn’t agree He stayed with me a while then they scolded him and told him to go out I was sad and cried Not every case was presented so negatively A 44-year-old interviewee’s description of her experience highlights the variability of local engagement with health services: The health staff told my husband to go out, so he didn’t stay I wanted him to be there so I felt sad and afraid However, I trusted the health staff Discussion and conclusions Current data concerning maternal health utilisation by the many varied minority ethnic groups in Vietnam are limited The secondary and primary data reported in this paper provide new insight into Hmong and Thai childbirth practices and current engagement with maternal health services As government health facilities (particularly the CHC) were situated relatively close to the communities included in the field study, conventionally cited barriers such as geographical remoteness not adequately explain low service attendance The study identified an informed preference and selectivity in behaviour related to maternity Despite some use of ANC services, overall attendance at health services for delivery was low Home birth without the presence of health staff was the dominant scenario Facility delivery was reported largely on occasions of problematic labours (some of which may have been emergency cases) or by those who felt a facility birth offered greater hygiene and safety than home birth These findings confirm existing knowledge regarding women’s responses to services being based on pragmatic calculations as to how these services might enhance their lives (Lock and Kaufert 1998) Field study findings challenge present notions of the less ‘engaged’ Hmong and ‘more assimilated’ Thai, highlighting the need for more comprehensive data collection across minority ethnic groups in Vietnam in order to deepen current understanding of maternal health-seeking behaviour Current presentation of ‘traditional customs’ as a specific obstacle to maternal service utilisation not only implicitly places the onus on minority women to change behaviour and engage more comprehensively with services, but simultaneously inhibits examination by policy-makers and practitioners of the cultural divide between existing health services and local practices, and the ways in which service provision may be failing to meet the needs and preferences of minority women Both Downloaded by [81.84.120.101] at 09:42 03 February 2013 878 J White et al secondary data and field study findings reveal the continuing importance of sitting, squatting and kneeling delivery positions, and the presence of husbands and other support persons during home childbirth among both Hmong and Thai communities Unnecessarily medicalised approaches to non-emergency delivery at all state health facilities, where practitioners are obliged to insist on supine (lying on the back) delivery and prohibit the attendance of husbands and female relatives during childbirth, are therefore unlikely to correspond to the desires of users from such minority groups This latter measure is not, in fact, formulated in the National Standard Guidelines on Reproductive Health (MOH 2009), nevertheless, a phenomenon is identifiable which has already been observed in other South-east Asian settings, whereby medicalisation processes are excluding men from childbirth (Merli 2011) While the presence of skilled attendants at deliveries is vital to reduce maternal mortality and ensure the best medical outcome for mothers and newborns (WHO 2006), this does not preclude approaches to safe delivery (be this at home or at a facility) which correspond more closely with local preferences Supine delivery may facilitate the work of doctors and midwives, yet upright delivery positions, longpreferred in non-industrialised societies, are known to have clinical advantages (Gupta and Hofmeyr 2004, Kroeger 2004, Terry et al 2006, Lawrence et al 2009) Furthermore, delivery outcomes can improve when a known support person accompanies a parturient throughout labour (Kroeger 2004) Indeed, mobility and a choice of position throughout labour, and the presence of a chosen companion, are both international standards of good practice for non-emergency delivery (WHO 2006) The failure of state efforts to incorporate ethnic minority populations in modernisation programmes through centralised ‘one-size-fits-all’ approaches, in Vietnam and elsewhere in South-east Asia, have been well-documented (Duncan 2008, Humphreys and Vu 2008) The findings of the reported study have important implications regarding the need for policy-makers both in Vietnam and the wider region to move beyond linear approaches and develop nuanced service modalities which engage with and attempt to accommodate cultural preferences Study results have already been used to stimulate discussion within local health authorities and medical training institutes in the provinces where the research took place, and also amongst MOH representatives, on reforming maternal health approaches in line with international standards of best practice Well-documented pilot projects where women are provided with more delivery options, including those safely practiced by minority peoples, will be needed to translate research findings into new policy and practice Experience outside South-east Asia demonstrates how efforts to move away from a uniform, medicalised approach and provide ‘culturally accessible services’ can transform minority women’s demand for state maternal health services (Morrow 1986, Gabrysch et al 2009) The participatory identification of mutually acceptable delivery methods by maternal health staff and local women has resulted in more culturally inclusive services, including the facilitation of customary squatting birthing positions and systematic preservation of the placenta for ritual purposes (Gabrysch et al 2009) The potential for similar approaches in collaboration with the communities studied is self-evident This could lead to increased home birth attendance by staff trained in local delivery methods as well Global Public Health 879 as the adaptation of service facilities to meet user preferences Health posts serving Hmong communities could supply a stool during labour and the placenta could be released to families through routine policy rather than local improvisation, while health posts serving Thai communities could be adapted for the suspension of the pieu Women’s desire to remain clothed or covered during labour could be respected Together with the wider (yet critical) issue of increasing the number of minority health practitioners working at health posts, such measures have the potential to transform the current faltering relationship between Hmong and Thai minority women and maternal health services It could be argued, moreover, that similar strategies should be applied to all maternal health services serving ethnically and culturally diverse clientele Downloaded by [81.84.120.101] at 09:42 03 February 2013 Acknowledgements The authors thank the villagers who participated in the study, the health staff in Dien Bien and Ha Giang, Medical Committee Netherlands Vietnam (MCNV), and the main donor of the programme under which the study was conducted, the Royal Netherlands Embassy in Hanoi Notes Document No 692/CN-SYT on Ethical Clearance, Dien Bien; Document No 725/UBNDVX on Ethical Clearance, Ha Giang Compared to around 10% amongst the Kinh This woman subsequently became a traditional midwife Food traditionally prepared to restore a parturient’s strength following delivery It is possible that interviewees were uncomfortable stating simply they preferred home birth to delivering at a health facility However, this does not invalidate the subsequent analysis Behaviour should be considered in historical perspective given that the local CHC was only established in 2000 Still, of all respondents who delivered in 2001 or after, less than half (20/42; just under 48%) gave birth at a health post References Adams, S.J., 2005 Vietnam’s healthcare system: a macroeconomic perspective In: International Symposium on Health Care Systems in Asia, 21Á22 January 2005 Tokyo: Hitotsubashi University Axelson, H., Bales, S., Pham, D.M., Ekman, B., and Gerdtham, G., 2009 Health financing for the poor produces promising short-term effects on utilization and out-of-pocket expenditure International Journal for Equity in Health, (20) Available from: http://www equityhealthj.com/content/pdf/1475-9276-8-20.pdf Baulch, B., Truong, T.K.C., Haughton, D., and Haughton, J., 2004 Ethnic minority development in Vietnam: a socio-economic perspective Washington, DC: World Bank Policy Research Working Paper 2836 Buekens, P., 2001 Over-medicalisation of 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