Towards better maternal and newborn care in rural Vietnam

A German-supported programme builds provider confidence and changes client perceptions

This little jaundice patient is well taken care of and kept warm in an incubator

“I think the services here are quite good, the equipment is new and the hospital is very clean. The health staff is very dedicated in looking after us, they check in on my daughter’s condition many times a day. I don’t think that there is a big difference between district and provincial hospitals anymore, that is why I took my daughter here when she got a high fever”

says Mrs Dao Thi Kim Lien who took her 8 months-old daughter Ni to Dong Xuan District Hospital in Phu Yen province.

We met Mrs Dao in January 2015 when our research team went to Phu Yen province in Southern Vietnam to conduct an assessment of maternal and newborn referral practices in selected provincial and district health facilities. We wanted to find out whether something had changed in these practices since the programme “Strengthening Provincial Health Systems” which GIZ implements on behalf of BMZ had started its support in 2009. But why do such referral practices matter?

Why referral practices matter

In remote provinces in Vietnam district hospitals often lack doctors, nurses and midwives as well as essential medical equipment. When it comes to a more complicated case or an emergency, many people fear that their local health services will not be able to provide them with the required quality of care. To be on the safe side, they simply bypass the district hospitals and seek medical treatment at provincial level, even though this creates extra costs for them. At provincial and national level hospitals this leads to overcrowding and enormous workloads for the medical staff, which in turn can result in delays in the treatment of emergency cases.

Delays in treatment and lack of expertise in managing emergency cases at the lower levels of the health system are central causes for Vietnam’s newborn mortality. The German supported health programme set out to address this double challenge.

From the start, it focussed on strengthening health workers’ capacities both on district and provincial level and on putting a functional referral system into place:  Where health workers at the local level assess risk factors in a reliable manner, treat straightforward cases themselves and only refer patients with an actual risk or with serious complications to higher level facilities, both newborn and maternal mortality can be reduced. Unnecessary costs to the system can be avoided if the more complex diagnostic and clinical services at the higher level are only used for patients who actually need them. And patients who can be treated at local level can save the costs for transportation, food and accommodation that are part of hospitalisations at provincial and national level.

Measures to build a functional referral system

To achieve such a functioning system, the GIZ programme strengthened health workers’ capacities at district and provincial level through training measures as well as advisory services for doctors, nurses and midwives.

The training workshops covered various aspects of newborn and obstetric care, including the management of emergency cases, prenatal ultrasound and rational drug use. Advisory services helped the hospital management to introduce quality management measures and to establish quality improvement teams. As a result, injection safety, infection control and timely internal referrals of newborns with intensive care needs were improved.

KfW, which implements the financial cooperation component of the German programme, provided district and provincial hospitals with essential equipment for maternal and newborn care, such as incubators for premature babies and surgical equipment.

At the national level, the programme supported the ministry of health in the development of guidelines for emergency obstetric care and for essential newborn care. Both sets of guidelines were since approved for nationwide use in continuous medical education courses.

Assessing changes

To assess changes in provider confidence and in client perceptions our research team conducted focus group discussions with doctors, nurses and midwives as well as semi-structured interviews with hospital managers, patients and caregivers.  

In addition, we carried out a systematic assessment of the referral practices between district, provincial and national hospitals. Through the hospitals’ German-supported hospital management information systems (HMIS), we had access to 10.328 newborn and 20.627 obstetric patient records to assess quantitative referral data.

Overall, the assessment showed some promising developments but we were also reminded that building providers’ confidence and clients’ trust in local services requires perseverance from all sides.

Many pregnant women don’t trust their district hospitals

Since 2012 referral patterns for pregnant women have only been changing slowly. Many of them are still referred to higher level facilities for a normal delivery or for routine antenatal care because their families don’t trust the available local services. A pregnant woman at the Provincial Hospital in Thai Binh Province said:

“Because this is my first child I’m really worried about the delivery and that is why I came to the Provincial Hospital. Most of the people in my neighbourhood come here too, because in the hospital close to our village there were several death cases, so everyone is afraid.”

In contrast, the German-supported measures have begun to have an effect on provider confidence: A number of doctors at the district hospitals confirmed that they now felt more confident to provide obstetric emergency care since they had taken part in several trainings on this topic and because their facilities were now equipped with the necessary tools and instruments. A doctor at Dong Xuan District Hospital in Phu Yen told us:

“The handling of emergency cases is much better, I think. Because now we know very well what to do first and all the other steps are very clear. In the past, we were not that organized in handling a case of haemorrhage.”

Quality care for newborns at the district level

The situation looks more promising when it comes to healthcare for newborns. Even though the social health insurance allows parents to choose whether they want their sick baby to be treated at local, provincial or national level, only 27% of newborn patients were referred on to higher levels. Reasons for such referrals included prematurity, respiratory distress and infections, conditions which doctors in district hospitals don’t feel confident to treat themselves.

At the provincial level, however, the trainings and advisory services GIZ has been providing have already had a marked impact on referral practices: Only 2% of premature babies are currently referred from provincial hospitals to specialised facilities on national level. Compared to a similar study conducted in 2012, these figures demonstrate a trend towards reduced referrals to higher level facilities .

A paediatric doctor at Thai Binh Provincial Hospital who took part in a GIZ-organised training thought that the trainings’ focus on improving communication and feedback mechanisms between hospitals at different levels helped to reduce unnecessary referrals:

“[It] helped us a lot in improving the communication between different levels. I remember that the training was attended by staff from commune health stations, district and provincial hospitals. We learned from the teachers but also through discussion among us and exchanged phone numbers for further discussion or support.”

Better communication and provider confidence are important steps

Additional feedback from different health workers points in a similar direction: Improving the communication and feedback systems between the different levels of the health system are one promising approach to building both the capacities and the confidence of health workers at provincial and district levels to provide more comprehensive newborn and obstetric services.

But let us return to Mrs Dao who felt that her daughter was well looked after in her district hospital. Just like her, many parents have begun to develop trust in local health services and are using them, which, in turn, builds the confidence of their doctors and nurses. While it will still take some time to overcome pregnant women’s fears, doctors’, nurses’ and midwives’ strengthened capacities and improved confidence are important steps towards a fully functional referral system and quality obstetric and newborn services at lower level health care settings in Vietnam.

Anne Geweniger

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