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Knowledge and provision practices regarding medical abortion among public providers in Hanoi, Khanh Hoa, and Ho Chi Minh City, Vietnam
International Journal of Gynecology and Obstetrics 124 (2014) 216–221
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International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Knowledge and provision practices regarding medical abortion among public providers in Hanoi, Khanh Hoa, and Ho Chi Minh City, Vietnam Thoai D. Ngo a,b,⁎, Caroline Free a, Hoan T. Le c, Phil Edwards a, Kiet H.T. Pham d, Yen B.T. Nguyen d, Thang H. Nguyen e a
Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK Research, Monitoring and Evaluation Team, Health System Department, Marie Stopes International, London, UK Department of Environmental Health, Hanoi Medical University, Hanoi, Vietnam d Department of Health Economics, Hanoi Medical University, Hanoi, Vietnam e Research and Metrics Team, Marie Stopes International Vietnam, Hanoi, Vietnam b c
a r t i c l e
i n f o
Article history: Received 11 June 2013 Received in revised form 15 August 2013 Accepted 5 November 2013 Keywords: Attitudes Knowledge Manual vacuum aspiration Medical abortion Mifepristone Misoprostol Practices Vietnam
a b s t r a c t Objective: To assess public service providers’ knowledge of medical abortion (MA) and practices, and perspectives on expanding the use of MA to primary and secondary health facilities in Vietnam. Methods: A cross-sectional study was conducted via an interviewer-administered questionnaire among abortion providers (n = 905) from public health facilities between August 2011 and January 2012. Results: Overall, 31.1% of providers performed both surgical and medical abortions; 68.9% offered only surgical abortion. Providers were knowledgeable about the regimen/dosage of mifepristone plus misoprostol regimen; however, knowledge scores were low for gestational age limits for MA, adverse effects of the combined drug regimen, and safety and effectiveness of MA compared with surgical abortion. Knowledge scores were significantly lower among providers in rural areas than among those in urban settings. A large proportion of providers (82.9%) thought that MA should be expanded to primary and secondary health facilities. Perceived barriers to MA expansion included lack of knowledge and training, qualified staff, adequate drug supplies, equipment, or facilities, guidelines and protocols on MA, and patient awareness. Conclusion: Provision of MA in Vietnam was found to be disproportionate to surgical abortion provision and to vary by region. Knowledge of MA was moderate, but poorer among providers in rural settings. © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Since the early 1960s, abortion has been permitted in Vietnam to support Vietnam’s family planning program [1]. To expand choice and access, medical abortion (MA) was first introduced into the country in 1992 through a clinical study [2]. Since then, 3 clinical trials have evaluated the efficacy and acceptability of first-trimester MA among Vietnamese women and have found high completion rates (N 93%), satisfaction (N 93%), and acceptability (N 90%) [3–5]. Surgical termination using manual vacuum aspiration (MVA) can be provided by doctors and/or midwives at all Vietnam’s public health administrative levels. However, MA using a regimen of mifepristone plus misoprostol for first-trimester termination is permitted only by obstetricians/gynecologists at the central, provincial, and district level [2] in centers for reproductive health (CRHs), hospital abortion clinics,
⁎ Corresponding author at: 1 Conway Street, London, UK W1T 6LP. Tel.: +44 020 7034 2352; fax: +44 020 7034 2372. E-mail address: [email protected] (T.D. Ngo).
and specialized hospitals in urban or peri-urban areas. Midwives are not permitted to independently manage MA cases. Despite evidence that MA is a safe and effective alternative to MVA in Vietnam, a 2007 assessment showed that provision of MA at public health facilities varied greatly across Vietnamese cities: 2% in Da Nang, 10% in Hanoi, and 25% in Ho Chi Minh City (HCMC) [6]. Another survey revealed that the national percentage of abortions performed via MA was only 5%, compared with 86% performed via MVA [7]. Given governmental support for the introduction of MA and evidence showing high effectiveness, satisfaction, and acceptability in Vietnam [3–5], it is unclear why this method is not provided more widely. Vietnam’s national reproductive health policy indicates that women eligible for terminations should be offered an informed and voluntary choice of method. Because women often rely on providers for information and advice, however, the provider’s own knowledge and attitudes regarding methods might influence patient choice. There has been no nationally representative quantitative survey on MA knowledge and provision practices in Vietnam. The last national assessment on MA delivery in 2003 indicated that MA knowledge among public providers had not spread beyond those actively involved in MA
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T.D. Ngo et al. / International Journal of Gynecology and Obstetrics 124 (2014) 216–221
research [2]. A study in 2007 indicated that Vietnamese public and private providers required further training on MA methods [6]. Understanding providers’ MA knowledge and provision practices in Vietnam might assist policymakers in addressing knowledge shortcomings and practical problems affecting abortion provision. The primary aim of the present study was therefore to examine the current knowledge, attitudes, and practices of MA delivery among abortion providers within the public health system in Hanoi, Khanh Hoa province, and HCMC, Vietnam. A secondary aim was to explore abortion providers’ perspectives on expanding MA to primary and secondary health facilities in Vietnam. 2. Materials and methods The present cross-sectional quantitative survey was conducted among abortion providers at public health facilities in Hanoi municipality, Khanh Hoa province, and HCMC from August 1, 2011, to January 31, 2012. The study received ethical approval from institutional review boards at the London School of Hygiene and Tropical Medicine and the Hanoi School of Public Health. Participants provided written informed consent prior to participation. A multi-stage sampling strategy was implemented to select the provinces, health facilities, and service providers. Selected provinces/ municipalities were sampled to represent geographic and cultural differences within the country. The following facilities were included: (1) central sexual and reproductive health (SRH) specialist/general hospitals; (2) provincial SRH specialist/general hospitals; (3) provincial CRHs; (4) district hospitals; (5) district CRHs; and (6) commune health stations (CHSs). A master list of all health facilities in the 3 regions was obtained from the municipal and provincial departments of health. All specialist hospitals and CRHs specializing only in SRH service provision were selected owing to the limited numbers of these facilities at each health administrative level. A random sampling strategy was used to select 50% of all non-SRH specialized facilities (general hospitals and CHSs). In total, 62 health facilities were included in the survey (Table 1). Eligible providers invited to participate included physicians and midwives providing abortion services (MVA, MA, or both) at any of the selected facilities. Participation was voluntary, and the survey was conducted using a structured questionnaire administered face to face by an interviewer in a private office at the participant’s place of work. Providers at CHSs were invited to the district general hospital associated with their CHS for interview (Table 2). The sample size was calculated with the assumption that at least 50% of providers administer MA and MVA. It was determined that a sample size of 783 providers would be required to detect the proportion of abortion providers performing MA to within ± 5% of the true value with a 95% confidence interval. Allowing for a 10% nonresponse rate, the sample size was increased to 862.
Table 1 Number of facilities visited at different health administrative levels by region. Type of facilitya
Central specialist hospital Provincial specialist hospital Central general hospital Provincial general hospital Provincial CRH District general hospital District CRH Total
Region
Total
Hanoi
Khanh Hoa
HCMC
1 1 1 1 1 9 14
– – – 1 1 4 4
– 1 – 2 1 10 10
1 2 1 4 3 23 28 62
Abbreviations: CRH, center for reproductive health; HCMC, Ho Chi Minh City. a Note that commune health stations were not visited owing to study logistics. Providers at commune health stations were invited to the district general hospital to which their station belonged in order to participate in the interview.
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Table 2 Number of providers interviewed at the different types of public health facility by region. Type of facility
Central specialist hospital Provincial specialist hospital Central general hospital Provincial general hospital Provincial CRH District general hospital District CRH Commune health stationa Total
Region
Total
Hanoi
Khanh Hoa
HCMC
11 6 7 17 9 78 100 297 525
– – – 6 4 4 13 95 122
0 15 0 22 9 39 37 136 258
11 21 7 45 22 150 121 528 905
Abbreviations: CRH, center for reproductive health; HCMC, Ho Chi Minh City. a Providers at commune health stations were invited to the district general hospital to which their station belonged in order to participate in the interview.
Statistical analyses were performed via Stata version 11.1 (StataCorp, College Station, TX, USA). Because the proportion of health facilities sampled (primary sampling unit) was not consistent (100% of SRH specialist facilities versus 50% of general facilities), respondents had an unequal chance of being selected. Providers at general hospitals thus had half the chance of inclusion compared with providers at SRH specialist facilities. In the analysis, therefore, providers at general facilities were given twice the weight of providers from specialist SRH facilities. All analyses were performed using Stata survey commands to adjust for this sampling scheme and probability weights. Descriptive statistics were used to summarize characteristics, knowledge, and provision practices. χ2 tests were used to test for associations between binary variables, and t tests were used for continuous variables. A P value of less than 0.05 was considered statistically significant. 3. Results In total, 905 providers were included in the survey: 525 (58.0%) from Hanoi; 122 (13.5%) from Khanh Hoa; and 258 (28.5%) from HCMC (Table 3). More than half (58.3%) came from CHSs; 16.6% came from district CRHs; 13.4% came from district hospitals; and the remainder came from provincial general hospitals, CRHs, or specialist hospitals, or central specialist or general hospitals. The survey response rate was 99.6%. Most providers were midwives (74.9%); doctors comprised 23.0% of the study population. Among the 3 regions, Hanoi had the highest proportion of doctors. Most providers were female (96.7%), aged 25 years or older (94.0%), married (84.4%), and had at least 1 child (89%). Marital status varied significantly among the different regions (P = 0.015); 92.3% in Hanoi were married compared with 81.7% in Khanh Hoa and 69.8% in HCMC. Providers were evenly distributed between urban or peri-urban and rural areas (51.0% vs 49.0%). Hanoi and HCMC had a significantly higher proportion of urban or peri-urban providers compared with Khanh Hoa (P = 0.015). Overall, 68.9% of providers had midwifery training, 16.1% had medical doctorate training, 11.4% had obstetrics–gynecology training, and 3.6% had nursing training. More than half of the providers had 10 years or more of experience in abortion service provision. Medical training level (P = 0.03) and number of years of experience (P = 0.023) varied significantly among the 3 regions. Among the 905 providers, 31.1% performed MA and MVA, whereas 68.9% performed only MVA. The proportion performing both methods varied by region: 12.1% in Khanh Hoa, 27.1% in HCMC, and 36.8% in Hanoi. In total, 82.9% of participants reported that MA should be expanded to primary and secondary health facility levels (CHSs and district hospitals, respectively). When asked who should be permitted to perform MA if the service was expanded, 81.1% said physicians, 46.0% reported midwives, and 6.7% said nurses. The top 5 perceived barriers to MA
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T.D. Ngo et al. / International Journal of Gynecology and Obstetrics 124 (2014) 216–221
Table 3 Sociodemographic and provision characteristics of abortion providers by region. Characteristic
Types of provider Doctors (OB/GYNs or general physicians) Midwives Nurses Gender Male Female Age, y ≤24 25–34 35–44 ≥45 Marital status Single (never married) Married Divorced/separated Living with partner Number of children 0 1 2 3–4 Location Urban/peri-urban Rural Medical training received Nursing Midwifery Obstetrics/gynecology Other medical doctoral Experience ≤1 y 2–9 y 10–19 y 20–29 y 30–37 y Facility where providers spend the most time Private facility Current facility Private and public facility equally Other Service provision Surgical abortion only Surgical and medical abortion a
Percentage of overall sample
Percentage distribution for each region
(n = 905)
Hanoi (n = 525)
23.0 74.9 2.1
30.5 67.5 2.0
3.8 96.2 –
16.4 80.8 2.8
3.3 96.7
4.3 95.7
0.0 100
2.8 97.2
0.198
5.6 33.4 25.3 35.7
4.4 31.2 25.0 39.4
6.9 33.1 43.9 16.2
7.5 37.9 17.8 36.9
0.051
13.1 84.4 1.8 0.7
6.7 92.3 0.8 0.2
15.3 81.7 3.0 0.0
24.8 69.8 3.2 2.2
0.015
11.1 29.1 55.3 4.5
7.3 28.4 58.2 6.0
12.4 29.2 58.4 0.0
19.3 30.7 47.2 2.8
0.165
51.0 49.0
52.6 47.4
28.0 72.0
57.4 42.6
0.015
3.6 68.9 11.4 16.1
4.8 62.5 12.5 20.2
0.8 79.1 3.9 16.3
2.5 77.5 12.4 7.6
0.030
7.9 38.2 24.2 22.7 6.9
5.0 35.1 24.4 27.1 8.4
9.2 37.7 36.9 14.6 1.5
13.1 44.7 18.6 17.3 6.2
0.023
1.4 94.2 4.1 0.3
0.8 96.7 2.5 0.0
3.3 93.4 3.3 0.0
1.6 89.6 7.8 1.0
0.282
68.9 31.1
63.2 36.8
87.0 12.1
72.9 27.1
0.233
Khanh Hoa (n = 122)
HCMC (n = 258)
P valuea 0.045
P values given for differences between regions.
expansion were (1) lack of knowledge and training of providers at primary and secondary level health facilities (63.0%); (2) insufficient staff to take on additional service provision (42.7%); (3) inadequate drug
supplies, equipment or facilities (31.5%); (4) lack of guidelines and protocol on MA provision (27.5%); and (5) lack of patient awareness (26.6%) (Table 4).
Table 4 Provider’s perceptions on the expansion of medical abortion (n = 905). Question
Answer
Percentage response (n = 905)
MA should be expanded to lower (primary and secondary) health facilities?
Yes No Don’t know Physicians Midwives Nurses Lack of knowledge and training Not enough staff No adequate drug supplies or equipment/facilities Lack of guidelines/protocols Resistance/objection from doctors National/local legal barriers Increase in clinical workload Lack of suitable rooms or venues Pressure of having emergency services Increase in complications or failure Lack of patient awareness or knowledge
82.9 13.8 3.3 81.1 46.0 6.7 63.0 42.7 31.5 27.5 1.0 11.7 4.2 17.4 26.4 10.1 26.6
Who can provide MA if it is widely available at all health facilities?
Perceived barriers to MA provision at primary and secondary health facilities?
Abbreviation: MA, medical abortion.
T.D. Ngo et al. / International Journal of Gynecology and Obstetrics 124 (2014) 216–221
The survey included several questions related to national guidelines and the effectiveness and safety of MA. Among the 905 participants, 62.0% stated that MA can be performed at up to 9 weeks of gestation (in accordance with national guidelines); 10% reported that MA can be performed from 10 to 24 weeks, and 27% said that they did not know (Table 5). Most (92.6%) reported the correct dosage regimen for mifepristone plus misoprostol (96.7% among those providing both methods; 90.8% among those providing only MVA). The proportion of providers able to name the adverse effects associated with the mifepristone plus misoprostol regimen ranged from 16.4% for flushes or sweats to 54.3% for cramps. Providers who performed both methods scored significantly higher on naming diarrhea (37.8% vs 19.8%; P = 0.026) and flushes or sweats (22.0% vs 14.0%; P = 0.04) compared with providers performing only MVA. Only 27.8% stated that MA is as safe as MVA; 35.7% believed that MA is safer than MVA, 25.4% believed MVA is safer than MA, and 11.1% did not know. A small proportion (13.8%) mentioned that MA is as effective as MVA; almost half (47.9%) claimed that MA is more effective, 6.4% said that MVA is more effective; and the rest (31.9%) did not know. There was no significant difference in knowledge of gestational age limits, dosage, and safety and effectiveness of MA versus MVA between those providing both methods and individuals performing only MVA (Table 5). Compared with providers in rural areas, those in urban or peri-urban settings scored significantly higher on knowledge of MA legal gestation limits (47.0% vs 76.7%; P b 0.001), the correct regimen and dosage for the mifepristone plus misoprostol protocol (P b 0.001), adverse effects related to the MA regimen, and the effectiveness of MA versus MVA (P = 0.001) (Table 6). Subgroup analysis was conducted among providers who performed both methods (n = 255). During the week before the survey, 15.9% had performed 1 or more MAs, 12.6% had performed 10 or more MAs, and most (71.5%) had performed no MA procedures. The proportion distribution was similar for MVA performed within the past week (20.7%, ≥ 1 MVA; 9.3%, ≥ 10 MVAs; 70.0%, no MVAs).
219
Most providers (86.2%) instructed women to administer misoprostol at home; only 13.8% asked women to return to the health facility for misoprostol administration. 4. Discussion Overall, the providers’ knowledge of MA was moderate. Although providers were knowledgeable about the regimen and dosage of the mifepristone plus misoprostol protocol, they scored poorly on MA gestational age limits according to national guidelines, adverse effects related to the drug regimen, and the safety and effectiveness of MA compared with MVA. There was no difference in MA knowledge between providers performing both methods and those performing MVA only. Providers in rural areas scored significantly lower than urban providers on several knowledge-related items, probably because they had not received MA training; in addition, providers at CHSs are not permitted to perform MA. The present findings on providers’ knowledge of MA in Vietnam are similar to those of studies in China, which has similar abortion laws and health service administration [8,9]. In the present study, provision of MA was lower than provision of MVA; 31.1% of providers offered both methods, whereas 68.9% offered MVA only. MA provision varied by region (12.1% in Khanh Hoa, 27.1% in HCMC, and 36.8% in Hanoi), and was concentrated in urban or periurban settings. The inclusion of providers at CHSs in the sampling strategy might have led to an underestimation of the prevalence of MA provision. This uneven distribution is consistent with findings of an assessment in 2007 by the Population Council in Vietnam [6]. Among those who performed MA and MVA in the present survey, most offered home administration of misoprostol. Although home administration is not specified within Vietnamese national abortion guidelines, this practice is consistent with the recommendations of a systematic review [10] and the updated WHO abortion guidelines [11]. Most providers (82.9%) reported that MA should be expanded to primary and secondary health facilities, and 81.1% thought that physicians should administer MA if the service was expanded. However,
Table 5 Knowledge of medical abortion among abortion providers by type of termination services provided. Knowledge
Gestational age limit for MA according to national guidelines ≤9 wk 10–24 wk Don’t know Knowledge of MA regimen and dosage (unprompted) Correct MA regimen and dosage Incorrect MA regimen and dosage Don’t know Able to name adverse effects of MA (unprompted) Nausea Vomiting Diarrhea Headaches Dizziness Flushes/sweats Cramps Safety of medical versus surgical Surgical is safer Medical is safer Both as safe as each other Don’t know Effectiveness of medical versus surgical abortion Surgical is more effective Medical is more effective Both as effective Don’t know Abbreviation: MA, medical abortion. a P values given for differences between the 2 groups.
Percentage of overall sample (n = 905)
P valuea
Termination service provision Medical and surgical, % (n = 255)
Surgical only, % (n = 646)
62.0 10.0 27.0
68.2 9.6 22.2
59.3 10.2 30.5
0.452
92.6 4.9 2.5
96.7 3.3 0.0
90.8 5.5 3.7
0.494
48.5 31.1 25.4 30.1 33.7 16.4 54.3
60.0 45.1 37.8 37.5 41.2 22.0 61.8
43.2 24.8 19.8 26.8 30.4 14.0 51.0
0.132 0.069 0.026 0.189 0.108 0.044 0.249
25.4 35.7 27.8 11.1
19.8 35.3 31.3 13.6
27.9 35.9 26.2 10.0
0.448
6.4 47.9 13.8 31.9
5.0 55.6 14.6 24.8
7.0 44.5 13.4 35.1
0.393
220
T.D. Ngo et al. / International Journal of Gynecology and Obstetrics 124 (2014) 216–221
Table 6 Knowledge of medical abortion among abortion providers by location of providers. Percentage of overall sample (n = 905)
Gestational age limit for MA according to national guidelines ≤9 wk 10–24 wk Don’t know Knowledge of MA regimen and dosage (unprompted) Correct MA regimen and dosage Incorrect MA regimen and dosage Don’t know Able to name adverse effects of MA (unprompted) Nausea Vomiting Diarrhea Headaches Dizziness Flushes/sweats Cramps Safety of medical versus surgical abortion Surgical is safer Medical is safer Both as safe as each other Don’t know Effectiveness of medical versus surgical abortion Surgical is more effective Medical is more effective Both as effective Don’t know
P valuea
Location of providers Urban/peri-urban, % (n = 377)
Rural, % (n = 528)
62.2 9.9 27.9
76.7 9.8 13.5
47.0 10.0 43.0
b0.001
92.3 4.8 2.9
93.1 1.8 5.1
91.5 8.0 0.6
b0.001
48.6 31.3 25.2 30.3 33.7 16.3 54.2
60.9 40.2 35.1 37.8 41.1 19.6 60.9
35.9 22.1 15.0 22.6 26.0 12.9 47.3
0.016 0.037 0.006 0.016 0.001 0.013 0.0.51
25.3 36.0 27.7 11.0
22.4 39.5 31.7 6.5
28.2 32.3 23.6 15.7
0.051
6.3 48.1 13.7 31.9
7.1 56.4 17.5 45.1
5.6 39.5 9.8 45.1
0.001
Abbreviation: MA, medical abortion. a P values given for differences between the 2 groups.
almost half of the providers thought that midwives should also be permitted to perform MA at these facilities. Most (76%) healthcare workers who performed both methods were doctors; however, 19% were midwives and 4% were nurses. Although this practice is not aligned with Vietnam’s national abortion guidelines, it is evidenceinformed. A systematic review showed no statistical differences in the effectiveness and safety of first-trimester MA performed by mid-level providers compared with that performed by physicians [12]. In addition, it has been suggested that provision and management of MA by midwives or nurses is most cost-effective in resource-limited settings owing to the salary costs and scarcity of obstetrician–gynecologists [13]. However, no assessment in Vietnam at the primary health level has compared first-trimester MA administered by trained mid-level providers with that administered by doctors. Providers in the present survey cited barriers to MA expansion that included lack of knowledge or training of providers at primary and secondary level health facilities, insufficient staff for additional service provision, inadequate drug supplies and/or equipment, lack of guidelines and protocol on MA provision, and lack of patient awareness. Two studies in China found similar concerns among providers [8,9]. Formalized training programs would resolve any lack of knowledge and training: because MVA is available at primary and secondary health facilities, there should be no reason why providers who are currently administering MVA cannot perform MA. Locally owned educational materials are needed both for MA providers and for providers indirectly involved with abortion-seeking women to allow adequate patient information and counseling. Lack of drug supplies is a legitimate concern; however, Vietnam has 3 companies that produce mifepristone and misoprostol locally at affordable prices (Mifestad-200/misoprostol, STADA; MIFE-200/ misoprostol, Pharbaco Central Pharmaceutical JSC; Mifepristone CIEL/ misoprostol, Ba Dinh Pharmaceutical Company) [14]. As a result, procuring these drugs and setting up a supply chain should not be challenging because these products are currently available in public
health facilities. Regarding inadequate equipment and/or facilities, primary and secondary health facilities already provide MVA; therefore, most equipment should already be in place. Furthermore, home-based MA might reduce the amount of clinic visits and equipment required. Home-based MA has been shown to be safe and effective [10], and studies suggest that many women favor it [15,16]. Studies are needed to evaluate how MA training should be structured and rolled out, and operational or pilot studies are necessary to assess the feasibility and acceptability of mid-level MA provision in rural areas and the types of support required by women during this process. A cost analysis is also needed to compare the direct and indirect costs of MA versus MVA at different health administrative levels within Vietnam. The present study represents a large cross-sectional quantitative and nationally representative survey among abortion providers in Vietnam with the primary intention of investigating MA knowledge and provision practices. Providers were included from all health administrative levels. Previous surveys in Vietnam and other settings have used small sample sizes and purposive sampling strategies [2,9,17–19]. The present study has some limitations owing to the cross-sectional nature of the data and the use of self-reported measures. In addition, the regions sampled represented more established municipalities and provinces, which might not be representative of rural or smaller provinces in Vietnam. Furthermore, other surveys [8,9] have explored general factors such as the safety of MA versus giving birth, and aspects such as legal consent and the association of abortion with mental health. The present analysis focused on more pragmatic knowledge measurements, which might not have captured all knowledge measurements, although existing literature suggests no association between these proxy measurements of knowledge and MA provision [8,9]. Last, findings from the present study cannot be generalized to other settings, because abortion service provision is dependent on national policies and cultural norms. In conclusion, MA provision in Vietnam is disproportionate to MVA provision and varies by region. Providers’ knowledge of MA was
T.D. Ngo et al. / International Journal of Gynecology and Obstetrics 124 (2014) 216–221
moderate and lower in rural settings. Most providers believed that MA should be expanded to primary and secondary health facilities; however, they noted several barriers related to the knowledge and/or competency of providers, inadequate facilities, and poor patient awareness. Acknowledgments Marie Stopes International provided funding for the study. Conflict of interest The authors have no conflicts of interest. References [1] Sedgh G, Henshaw SK, Singh S, Bankole A, Drescher J. Legal abortion worldwide: incidence and recent trends. Perspect Sex Reprod Health 2007;39(4):216–25. [2] Ganatra B, Bygdeman M, Phan BT, Nguyen DV, Vu ML. From research to reality: the challenges of introducing medical abortion into service delivery in Vietnam. Reprod Health Matters 2004;12(24 Suppl.):105–13. [3] Elul B, Hajri S, Ngoc NN, Ellertson C, Slama CB, Pearlman E, et al. Can women in less-developed countries use a simplified medical abortion regimen? Lancet 2001;357(9266):1402–5. [4] Ngoc NT, Nhan VQ, Blum J, Mai TT, Durocher JM, Winikoff B. Is home-based administration of prostaglandin safe and feasible for medical abortion? Results from a multisite study in Vietnam. BJOG 2004;111(8):814–9. [5] Nguyen TN, Blum J, Durocher J, Quan TT, Winikoff B. A randomized controlled study comparing 600 versus 1,200 μg oral misoprostol for medical management of incomplete abortion. Contraception 2005;72(6):438–42. [6] Nha VQ, Le TPM, Ngo VQ, Nguyen QC. Medical Abortion in Vietnam: Policy and the Situation of Service Provision in Private and Public Health Facilities in Ha Noi, Da Nang, and HCMC. Population Council: Hanoi; 2008.
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[7] Nguyen M. Vietnam National Abortion Survey. Hanoi: The Committee for Population, Family and Children; 2002. [8] Ji N, Zhou Y, Zhang Y, He D, Pang C, Xi M, et al. Medical abortion service in rural areas of Henan Province, China: a provider survey. J Obstet Gynaecol Res 2013;39(3): 672–9. [9] Cheng Y, Zhou Y, Zhang Y, Jiang X, Xi M, Gan K, et al. Study of knowledge and attitudes on medical abortion among Chinese health providers. Int J Gynecol Obstet 2012;118(Suppl. 1):S28–32. [10] Ngo TD, Park MH, Shakur H, Free C. Comparative effectiveness, safety and acceptability of medical abortion at home and in a clinic: a systematic review. Bull World Health Organ 2011;89(5):360–70. [11] World Health Organization. Safe abortion: technical and policy guidance for health systems. 2nd ed. 2012. http://apps.who.int/iris/bitstream/10665/70914/ 1/9789241548434_eng.pdf. Published 2012. Accessed January 12, 2013. [12] Ngo TD, Park MH, Free C. Safety and effectiveness of termination services performed by doctors versus midlevel providers: a systematic review and analysis. Int J Womens Health 2013;5:9–17. [13] Singh S. Hospital admissions resulting from unsafe abortion: estimates from 13 developing countries. Lancet 2006;368(9550):1887–92. [14] Asia Safe Abortion Partnership. Country Profile – Vietnam. http://www.asap-asia. org/country-profile-vietnam.html. Published 2012. Accessed January 12, 2013. [15] Boersma AA, Meyboom-de Jong B, Kleiverda G. Mifepristone followed by home administration of buccal misoprostol for medical abortion up to 70 days of amenorrhoea in a general practice in Curaçao. Eur J Contracept Reprod Health Care 2011;16(2):61–6. [16] Lohr PA, Wade J, Riley L, Fitzgibbon A, Furedi A. Women’s opinions on the home management of early medical abortion in the UK. J Fam Plann Reprod Health Care 2010;36(1):21–5. [17] Okonofua FE, Hammed A, Abass T, Mairiga AG, Mohammed AB, Adewale A, et al. Private medical providers’ knowledge and practices concerning medical abortion in Nigeria. Stud Fam Plann 2011;42(1):41–50. [18] Omo-Aghoja LO, Hammed A, Okonofua FE, Okpani OA, Koroye OC, Ojobo S, et al. A survey of attitudes and practices of reproductive health and family planning services among private medical practitioners in four states of the Niger-Delta region of Nigeria. Qual Prim Care 2011;19(5):325–34. [19] Gan K, Zhang Y, Jiang X, Meng Y, Hou L, Cheng Y. Perspectives of Chinese healthcare providers on medical abortion. Int J Gynecol Obstet 2011;114(1):15–7.
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International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Knowledge and provision practices regarding medical abortion among public providers in Hanoi, Khanh Hoa, and Ho Chi Minh City, Vietnam Thoai D. Ngo a,b,⁎, Caroline Free a, Hoan T. Le c, Phil Edwards a, Kiet H.T. Pham d, Yen B.T. Nguyen d, Thang H. Nguyen e a
Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK Research, Monitoring and Evaluation Team, Health System Department, Marie Stopes International, London, UK Department of Environmental Health, Hanoi Medical University, Hanoi, Vietnam d Department of Health Economics, Hanoi Medical University, Hanoi, Vietnam e Research and Metrics Team, Marie Stopes International Vietnam, Hanoi, Vietnam b c
a r t i c l e
i n f o
Article history: Received 11 June 2013 Received in revised form 15 August 2013 Accepted 5 November 2013 Keywords: Attitudes Knowledge Manual vacuum aspiration Medical abortion Mifepristone Misoprostol Practices Vietnam
a b s t r a c t Objective: To assess public service providers’ knowledge of medical abortion (MA) and practices, and perspectives on expanding the use of MA to primary and secondary health facilities in Vietnam. Methods: A cross-sectional study was conducted via an interviewer-administered questionnaire among abortion providers (n = 905) from public health facilities between August 2011 and January 2012. Results: Overall, 31.1% of providers performed both surgical and medical abortions; 68.9% offered only surgical abortion. Providers were knowledgeable about the regimen/dosage of mifepristone plus misoprostol regimen; however, knowledge scores were low for gestational age limits for MA, adverse effects of the combined drug regimen, and safety and effectiveness of MA compared with surgical abortion. Knowledge scores were significantly lower among providers in rural areas than among those in urban settings. A large proportion of providers (82.9%) thought that MA should be expanded to primary and secondary health facilities. Perceived barriers to MA expansion included lack of knowledge and training, qualified staff, adequate drug supplies, equipment, or facilities, guidelines and protocols on MA, and patient awareness. Conclusion: Provision of MA in Vietnam was found to be disproportionate to surgical abortion provision and to vary by region. Knowledge of MA was moderate, but poorer among providers in rural settings. © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Since the early 1960s, abortion has been permitted in Vietnam to support Vietnam’s family planning program [1]. To expand choice and access, medical abortion (MA) was first introduced into the country in 1992 through a clinical study [2]. Since then, 3 clinical trials have evaluated the efficacy and acceptability of first-trimester MA among Vietnamese women and have found high completion rates (N 93%), satisfaction (N 93%), and acceptability (N 90%) [3–5]. Surgical termination using manual vacuum aspiration (MVA) can be provided by doctors and/or midwives at all Vietnam’s public health administrative levels. However, MA using a regimen of mifepristone plus misoprostol for first-trimester termination is permitted only by obstetricians/gynecologists at the central, provincial, and district level [2] in centers for reproductive health (CRHs), hospital abortion clinics,
⁎ Corresponding author at: 1 Conway Street, London, UK W1T 6LP. Tel.: +44 020 7034 2352; fax: +44 020 7034 2372. E-mail address: [email protected] (T.D. Ngo).
and specialized hospitals in urban or peri-urban areas. Midwives are not permitted to independently manage MA cases. Despite evidence that MA is a safe and effective alternative to MVA in Vietnam, a 2007 assessment showed that provision of MA at public health facilities varied greatly across Vietnamese cities: 2% in Da Nang, 10% in Hanoi, and 25% in Ho Chi Minh City (HCMC) [6]. Another survey revealed that the national percentage of abortions performed via MA was only 5%, compared with 86% performed via MVA [7]. Given governmental support for the introduction of MA and evidence showing high effectiveness, satisfaction, and acceptability in Vietnam [3–5], it is unclear why this method is not provided more widely. Vietnam’s national reproductive health policy indicates that women eligible for terminations should be offered an informed and voluntary choice of method. Because women often rely on providers for information and advice, however, the provider’s own knowledge and attitudes regarding methods might influence patient choice. There has been no nationally representative quantitative survey on MA knowledge and provision practices in Vietnam. The last national assessment on MA delivery in 2003 indicated that MA knowledge among public providers had not spread beyond those actively involved in MA
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research [2]. A study in 2007 indicated that Vietnamese public and private providers required further training on MA methods [6]. Understanding providers’ MA knowledge and provision practices in Vietnam might assist policymakers in addressing knowledge shortcomings and practical problems affecting abortion provision. The primary aim of the present study was therefore to examine the current knowledge, attitudes, and practices of MA delivery among abortion providers within the public health system in Hanoi, Khanh Hoa province, and HCMC, Vietnam. A secondary aim was to explore abortion providers’ perspectives on expanding MA to primary and secondary health facilities in Vietnam. 2. Materials and methods The present cross-sectional quantitative survey was conducted among abortion providers at public health facilities in Hanoi municipality, Khanh Hoa province, and HCMC from August 1, 2011, to January 31, 2012. The study received ethical approval from institutional review boards at the London School of Hygiene and Tropical Medicine and the Hanoi School of Public Health. Participants provided written informed consent prior to participation. A multi-stage sampling strategy was implemented to select the provinces, health facilities, and service providers. Selected provinces/ municipalities were sampled to represent geographic and cultural differences within the country. The following facilities were included: (1) central sexual and reproductive health (SRH) specialist/general hospitals; (2) provincial SRH specialist/general hospitals; (3) provincial CRHs; (4) district hospitals; (5) district CRHs; and (6) commune health stations (CHSs). A master list of all health facilities in the 3 regions was obtained from the municipal and provincial departments of health. All specialist hospitals and CRHs specializing only in SRH service provision were selected owing to the limited numbers of these facilities at each health administrative level. A random sampling strategy was used to select 50% of all non-SRH specialized facilities (general hospitals and CHSs). In total, 62 health facilities were included in the survey (Table 1). Eligible providers invited to participate included physicians and midwives providing abortion services (MVA, MA, or both) at any of the selected facilities. Participation was voluntary, and the survey was conducted using a structured questionnaire administered face to face by an interviewer in a private office at the participant’s place of work. Providers at CHSs were invited to the district general hospital associated with their CHS for interview (Table 2). The sample size was calculated with the assumption that at least 50% of providers administer MA and MVA. It was determined that a sample size of 783 providers would be required to detect the proportion of abortion providers performing MA to within ± 5% of the true value with a 95% confidence interval. Allowing for a 10% nonresponse rate, the sample size was increased to 862.
Table 1 Number of facilities visited at different health administrative levels by region. Type of facilitya
Central specialist hospital Provincial specialist hospital Central general hospital Provincial general hospital Provincial CRH District general hospital District CRH Total
Region
Total
Hanoi
Khanh Hoa
HCMC
1 1 1 1 1 9 14
– – – 1 1 4 4
– 1 – 2 1 10 10
1 2 1 4 3 23 28 62
Abbreviations: CRH, center for reproductive health; HCMC, Ho Chi Minh City. a Note that commune health stations were not visited owing to study logistics. Providers at commune health stations were invited to the district general hospital to which their station belonged in order to participate in the interview.
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Table 2 Number of providers interviewed at the different types of public health facility by region. Type of facility
Central specialist hospital Provincial specialist hospital Central general hospital Provincial general hospital Provincial CRH District general hospital District CRH Commune health stationa Total
Region
Total
Hanoi
Khanh Hoa
HCMC
11 6 7 17 9 78 100 297 525
– – – 6 4 4 13 95 122
0 15 0 22 9 39 37 136 258
11 21 7 45 22 150 121 528 905
Abbreviations: CRH, center for reproductive health; HCMC, Ho Chi Minh City. a Providers at commune health stations were invited to the district general hospital to which their station belonged in order to participate in the interview.
Statistical analyses were performed via Stata version 11.1 (StataCorp, College Station, TX, USA). Because the proportion of health facilities sampled (primary sampling unit) was not consistent (100% of SRH specialist facilities versus 50% of general facilities), respondents had an unequal chance of being selected. Providers at general hospitals thus had half the chance of inclusion compared with providers at SRH specialist facilities. In the analysis, therefore, providers at general facilities were given twice the weight of providers from specialist SRH facilities. All analyses were performed using Stata survey commands to adjust for this sampling scheme and probability weights. Descriptive statistics were used to summarize characteristics, knowledge, and provision practices. χ2 tests were used to test for associations between binary variables, and t tests were used for continuous variables. A P value of less than 0.05 was considered statistically significant. 3. Results In total, 905 providers were included in the survey: 525 (58.0%) from Hanoi; 122 (13.5%) from Khanh Hoa; and 258 (28.5%) from HCMC (Table 3). More than half (58.3%) came from CHSs; 16.6% came from district CRHs; 13.4% came from district hospitals; and the remainder came from provincial general hospitals, CRHs, or specialist hospitals, or central specialist or general hospitals. The survey response rate was 99.6%. Most providers were midwives (74.9%); doctors comprised 23.0% of the study population. Among the 3 regions, Hanoi had the highest proportion of doctors. Most providers were female (96.7%), aged 25 years or older (94.0%), married (84.4%), and had at least 1 child (89%). Marital status varied significantly among the different regions (P = 0.015); 92.3% in Hanoi were married compared with 81.7% in Khanh Hoa and 69.8% in HCMC. Providers were evenly distributed between urban or peri-urban and rural areas (51.0% vs 49.0%). Hanoi and HCMC had a significantly higher proportion of urban or peri-urban providers compared with Khanh Hoa (P = 0.015). Overall, 68.9% of providers had midwifery training, 16.1% had medical doctorate training, 11.4% had obstetrics–gynecology training, and 3.6% had nursing training. More than half of the providers had 10 years or more of experience in abortion service provision. Medical training level (P = 0.03) and number of years of experience (P = 0.023) varied significantly among the 3 regions. Among the 905 providers, 31.1% performed MA and MVA, whereas 68.9% performed only MVA. The proportion performing both methods varied by region: 12.1% in Khanh Hoa, 27.1% in HCMC, and 36.8% in Hanoi. In total, 82.9% of participants reported that MA should be expanded to primary and secondary health facility levels (CHSs and district hospitals, respectively). When asked who should be permitted to perform MA if the service was expanded, 81.1% said physicians, 46.0% reported midwives, and 6.7% said nurses. The top 5 perceived barriers to MA
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Table 3 Sociodemographic and provision characteristics of abortion providers by region. Characteristic
Types of provider Doctors (OB/GYNs or general physicians) Midwives Nurses Gender Male Female Age, y ≤24 25–34 35–44 ≥45 Marital status Single (never married) Married Divorced/separated Living with partner Number of children 0 1 2 3–4 Location Urban/peri-urban Rural Medical training received Nursing Midwifery Obstetrics/gynecology Other medical doctoral Experience ≤1 y 2–9 y 10–19 y 20–29 y 30–37 y Facility where providers spend the most time Private facility Current facility Private and public facility equally Other Service provision Surgical abortion only Surgical and medical abortion a
Percentage of overall sample
Percentage distribution for each region
(n = 905)
Hanoi (n = 525)
23.0 74.9 2.1
30.5 67.5 2.0
3.8 96.2 –
16.4 80.8 2.8
3.3 96.7
4.3 95.7
0.0 100
2.8 97.2
0.198
5.6 33.4 25.3 35.7
4.4 31.2 25.0 39.4
6.9 33.1 43.9 16.2
7.5 37.9 17.8 36.9
0.051
13.1 84.4 1.8 0.7
6.7 92.3 0.8 0.2
15.3 81.7 3.0 0.0
24.8 69.8 3.2 2.2
0.015
11.1 29.1 55.3 4.5
7.3 28.4 58.2 6.0
12.4 29.2 58.4 0.0
19.3 30.7 47.2 2.8
0.165
51.0 49.0
52.6 47.4
28.0 72.0
57.4 42.6
0.015
3.6 68.9 11.4 16.1
4.8 62.5 12.5 20.2
0.8 79.1 3.9 16.3
2.5 77.5 12.4 7.6
0.030
7.9 38.2 24.2 22.7 6.9
5.0 35.1 24.4 27.1 8.4
9.2 37.7 36.9 14.6 1.5
13.1 44.7 18.6 17.3 6.2
0.023
1.4 94.2 4.1 0.3
0.8 96.7 2.5 0.0
3.3 93.4 3.3 0.0
1.6 89.6 7.8 1.0
0.282
68.9 31.1
63.2 36.8
87.0 12.1
72.9 27.1
0.233
Khanh Hoa (n = 122)
HCMC (n = 258)
P valuea 0.045
P values given for differences between regions.
expansion were (1) lack of knowledge and training of providers at primary and secondary level health facilities (63.0%); (2) insufficient staff to take on additional service provision (42.7%); (3) inadequate drug
supplies, equipment or facilities (31.5%); (4) lack of guidelines and protocol on MA provision (27.5%); and (5) lack of patient awareness (26.6%) (Table 4).
Table 4 Provider’s perceptions on the expansion of medical abortion (n = 905). Question
Answer
Percentage response (n = 905)
MA should be expanded to lower (primary and secondary) health facilities?
Yes No Don’t know Physicians Midwives Nurses Lack of knowledge and training Not enough staff No adequate drug supplies or equipment/facilities Lack of guidelines/protocols Resistance/objection from doctors National/local legal barriers Increase in clinical workload Lack of suitable rooms or venues Pressure of having emergency services Increase in complications or failure Lack of patient awareness or knowledge
82.9 13.8 3.3 81.1 46.0 6.7 63.0 42.7 31.5 27.5 1.0 11.7 4.2 17.4 26.4 10.1 26.6
Who can provide MA if it is widely available at all health facilities?
Perceived barriers to MA provision at primary and secondary health facilities?
Abbreviation: MA, medical abortion.
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The survey included several questions related to national guidelines and the effectiveness and safety of MA. Among the 905 participants, 62.0% stated that MA can be performed at up to 9 weeks of gestation (in accordance with national guidelines); 10% reported that MA can be performed from 10 to 24 weeks, and 27% said that they did not know (Table 5). Most (92.6%) reported the correct dosage regimen for mifepristone plus misoprostol (96.7% among those providing both methods; 90.8% among those providing only MVA). The proportion of providers able to name the adverse effects associated with the mifepristone plus misoprostol regimen ranged from 16.4% for flushes or sweats to 54.3% for cramps. Providers who performed both methods scored significantly higher on naming diarrhea (37.8% vs 19.8%; P = 0.026) and flushes or sweats (22.0% vs 14.0%; P = 0.04) compared with providers performing only MVA. Only 27.8% stated that MA is as safe as MVA; 35.7% believed that MA is safer than MVA, 25.4% believed MVA is safer than MA, and 11.1% did not know. A small proportion (13.8%) mentioned that MA is as effective as MVA; almost half (47.9%) claimed that MA is more effective, 6.4% said that MVA is more effective; and the rest (31.9%) did not know. There was no significant difference in knowledge of gestational age limits, dosage, and safety and effectiveness of MA versus MVA between those providing both methods and individuals performing only MVA (Table 5). Compared with providers in rural areas, those in urban or peri-urban settings scored significantly higher on knowledge of MA legal gestation limits (47.0% vs 76.7%; P b 0.001), the correct regimen and dosage for the mifepristone plus misoprostol protocol (P b 0.001), adverse effects related to the MA regimen, and the effectiveness of MA versus MVA (P = 0.001) (Table 6). Subgroup analysis was conducted among providers who performed both methods (n = 255). During the week before the survey, 15.9% had performed 1 or more MAs, 12.6% had performed 10 or more MAs, and most (71.5%) had performed no MA procedures. The proportion distribution was similar for MVA performed within the past week (20.7%, ≥ 1 MVA; 9.3%, ≥ 10 MVAs; 70.0%, no MVAs).
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Most providers (86.2%) instructed women to administer misoprostol at home; only 13.8% asked women to return to the health facility for misoprostol administration. 4. Discussion Overall, the providers’ knowledge of MA was moderate. Although providers were knowledgeable about the regimen and dosage of the mifepristone plus misoprostol protocol, they scored poorly on MA gestational age limits according to national guidelines, adverse effects related to the drug regimen, and the safety and effectiveness of MA compared with MVA. There was no difference in MA knowledge between providers performing both methods and those performing MVA only. Providers in rural areas scored significantly lower than urban providers on several knowledge-related items, probably because they had not received MA training; in addition, providers at CHSs are not permitted to perform MA. The present findings on providers’ knowledge of MA in Vietnam are similar to those of studies in China, which has similar abortion laws and health service administration [8,9]. In the present study, provision of MA was lower than provision of MVA; 31.1% of providers offered both methods, whereas 68.9% offered MVA only. MA provision varied by region (12.1% in Khanh Hoa, 27.1% in HCMC, and 36.8% in Hanoi), and was concentrated in urban or periurban settings. The inclusion of providers at CHSs in the sampling strategy might have led to an underestimation of the prevalence of MA provision. This uneven distribution is consistent with findings of an assessment in 2007 by the Population Council in Vietnam [6]. Among those who performed MA and MVA in the present survey, most offered home administration of misoprostol. Although home administration is not specified within Vietnamese national abortion guidelines, this practice is consistent with the recommendations of a systematic review [10] and the updated WHO abortion guidelines [11]. Most providers (82.9%) reported that MA should be expanded to primary and secondary health facilities, and 81.1% thought that physicians should administer MA if the service was expanded. However,
Table 5 Knowledge of medical abortion among abortion providers by type of termination services provided. Knowledge
Gestational age limit for MA according to national guidelines ≤9 wk 10–24 wk Don’t know Knowledge of MA regimen and dosage (unprompted) Correct MA regimen and dosage Incorrect MA regimen and dosage Don’t know Able to name adverse effects of MA (unprompted) Nausea Vomiting Diarrhea Headaches Dizziness Flushes/sweats Cramps Safety of medical versus surgical Surgical is safer Medical is safer Both as safe as each other Don’t know Effectiveness of medical versus surgical abortion Surgical is more effective Medical is more effective Both as effective Don’t know Abbreviation: MA, medical abortion. a P values given for differences between the 2 groups.
Percentage of overall sample (n = 905)
P valuea
Termination service provision Medical and surgical, % (n = 255)
Surgical only, % (n = 646)
62.0 10.0 27.0
68.2 9.6 22.2
59.3 10.2 30.5
0.452
92.6 4.9 2.5
96.7 3.3 0.0
90.8 5.5 3.7
0.494
48.5 31.1 25.4 30.1 33.7 16.4 54.3
60.0 45.1 37.8 37.5 41.2 22.0 61.8
43.2 24.8 19.8 26.8 30.4 14.0 51.0
0.132 0.069 0.026 0.189 0.108 0.044 0.249
25.4 35.7 27.8 11.1
19.8 35.3 31.3 13.6
27.9 35.9 26.2 10.0
0.448
6.4 47.9 13.8 31.9
5.0 55.6 14.6 24.8
7.0 44.5 13.4 35.1
0.393
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Table 6 Knowledge of medical abortion among abortion providers by location of providers. Percentage of overall sample (n = 905)
Gestational age limit for MA according to national guidelines ≤9 wk 10–24 wk Don’t know Knowledge of MA regimen and dosage (unprompted) Correct MA regimen and dosage Incorrect MA regimen and dosage Don’t know Able to name adverse effects of MA (unprompted) Nausea Vomiting Diarrhea Headaches Dizziness Flushes/sweats Cramps Safety of medical versus surgical abortion Surgical is safer Medical is safer Both as safe as each other Don’t know Effectiveness of medical versus surgical abortion Surgical is more effective Medical is more effective Both as effective Don’t know
P valuea
Location of providers Urban/peri-urban, % (n = 377)
Rural, % (n = 528)
62.2 9.9 27.9
76.7 9.8 13.5
47.0 10.0 43.0
b0.001
92.3 4.8 2.9
93.1 1.8 5.1
91.5 8.0 0.6
b0.001
48.6 31.3 25.2 30.3 33.7 16.3 54.2
60.9 40.2 35.1 37.8 41.1 19.6 60.9
35.9 22.1 15.0 22.6 26.0 12.9 47.3
0.016 0.037 0.006 0.016 0.001 0.013 0.0.51
25.3 36.0 27.7 11.0
22.4 39.5 31.7 6.5
28.2 32.3 23.6 15.7
0.051
6.3 48.1 13.7 31.9
7.1 56.4 17.5 45.1
5.6 39.5 9.8 45.1
0.001
Abbreviation: MA, medical abortion. a P values given for differences between the 2 groups.
almost half of the providers thought that midwives should also be permitted to perform MA at these facilities. Most (76%) healthcare workers who performed both methods were doctors; however, 19% were midwives and 4% were nurses. Although this practice is not aligned with Vietnam’s national abortion guidelines, it is evidenceinformed. A systematic review showed no statistical differences in the effectiveness and safety of first-trimester MA performed by mid-level providers compared with that performed by physicians [12]. In addition, it has been suggested that provision and management of MA by midwives or nurses is most cost-effective in resource-limited settings owing to the salary costs and scarcity of obstetrician–gynecologists [13]. However, no assessment in Vietnam at the primary health level has compared first-trimester MA administered by trained mid-level providers with that administered by doctors. Providers in the present survey cited barriers to MA expansion that included lack of knowledge or training of providers at primary and secondary level health facilities, insufficient staff for additional service provision, inadequate drug supplies and/or equipment, lack of guidelines and protocol on MA provision, and lack of patient awareness. Two studies in China found similar concerns among providers [8,9]. Formalized training programs would resolve any lack of knowledge and training: because MVA is available at primary and secondary health facilities, there should be no reason why providers who are currently administering MVA cannot perform MA. Locally owned educational materials are needed both for MA providers and for providers indirectly involved with abortion-seeking women to allow adequate patient information and counseling. Lack of drug supplies is a legitimate concern; however, Vietnam has 3 companies that produce mifepristone and misoprostol locally at affordable prices (Mifestad-200/misoprostol, STADA; MIFE-200/ misoprostol, Pharbaco Central Pharmaceutical JSC; Mifepristone CIEL/ misoprostol, Ba Dinh Pharmaceutical Company) [14]. As a result, procuring these drugs and setting up a supply chain should not be challenging because these products are currently available in public
health facilities. Regarding inadequate equipment and/or facilities, primary and secondary health facilities already provide MVA; therefore, most equipment should already be in place. Furthermore, home-based MA might reduce the amount of clinic visits and equipment required. Home-based MA has been shown to be safe and effective [10], and studies suggest that many women favor it [15,16]. Studies are needed to evaluate how MA training should be structured and rolled out, and operational or pilot studies are necessary to assess the feasibility and acceptability of mid-level MA provision in rural areas and the types of support required by women during this process. A cost analysis is also needed to compare the direct and indirect costs of MA versus MVA at different health administrative levels within Vietnam. The present study represents a large cross-sectional quantitative and nationally representative survey among abortion providers in Vietnam with the primary intention of investigating MA knowledge and provision practices. Providers were included from all health administrative levels. Previous surveys in Vietnam and other settings have used small sample sizes and purposive sampling strategies [2,9,17–19]. The present study has some limitations owing to the cross-sectional nature of the data and the use of self-reported measures. In addition, the regions sampled represented more established municipalities and provinces, which might not be representative of rural or smaller provinces in Vietnam. Furthermore, other surveys [8,9] have explored general factors such as the safety of MA versus giving birth, and aspects such as legal consent and the association of abortion with mental health. The present analysis focused on more pragmatic knowledge measurements, which might not have captured all knowledge measurements, although existing literature suggests no association between these proxy measurements of knowledge and MA provision [8,9]. Last, findings from the present study cannot be generalized to other settings, because abortion service provision is dependent on national policies and cultural norms. In conclusion, MA provision in Vietnam is disproportionate to MVA provision and varies by region. Providers’ knowledge of MA was
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moderate and lower in rural settings. Most providers believed that MA should be expanded to primary and secondary health facilities; however, they noted several barriers related to the knowledge and/or competency of providers, inadequate facilities, and poor patient awareness. Acknowledgments Marie Stopes International provided funding for the study. Conflict of interest The authors have no conflicts of interest. References [1] Sedgh G, Henshaw SK, Singh S, Bankole A, Drescher J. Legal abortion worldwide: incidence and recent trends. Perspect Sex Reprod Health 2007;39(4):216–25. [2] Ganatra B, Bygdeman M, Phan BT, Nguyen DV, Vu ML. From research to reality: the challenges of introducing medical abortion into service delivery in Vietnam. Reprod Health Matters 2004;12(24 Suppl.):105–13. [3] Elul B, Hajri S, Ngoc NN, Ellertson C, Slama CB, Pearlman E, et al. Can women in less-developed countries use a simplified medical abortion regimen? Lancet 2001;357(9266):1402–5. [4] Ngoc NT, Nhan VQ, Blum J, Mai TT, Durocher JM, Winikoff B. Is home-based administration of prostaglandin safe and feasible for medical abortion? Results from a multisite study in Vietnam. BJOG 2004;111(8):814–9. [5] Nguyen TN, Blum J, Durocher J, Quan TT, Winikoff B. A randomized controlled study comparing 600 versus 1,200 μg oral misoprostol for medical management of incomplete abortion. Contraception 2005;72(6):438–42. [6] Nha VQ, Le TPM, Ngo VQ, Nguyen QC. Medical Abortion in Vietnam: Policy and the Situation of Service Provision in Private and Public Health Facilities in Ha Noi, Da Nang, and HCMC. Population Council: Hanoi; 2008.
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