Hoang Tu Anh, MD, MSc
Center for Creative Initiatives in Health and Population
【The article below is the fulltext of the article that appears in the fifteenth issue of the CGS Newsletter.】
Professor Tu Anh Hoang, who was introduced to us by ICU's visiting professor Thu Hong Khuat, kindly sent us an article on the current state of sexual and reproductive health in their country, Vietnam.
Since the International Conference on Population and Development in 1994 in Cairo, the Government of Vietnam has developed important programs, laws, and policies to improve reproductive health care and reduce the disparities between various regions and target groups. Some very progressive laws have been issued, such as the Law on HIV/AIDS Prevention and Control (2006), the Law on Gender Equality (2006), and the Law on Domestic Violence Prevention and Control (2007). However, data shows that there are still serious gaps in the reproductive and sexual health and care of disadvantaged and vulnerable women.
Contraceptive use in Vietnam is generally high and there is no significant difference between rural and urban areas. However, there is a big gap between women of high and low education, and between the Northern Delta and Tay Nguyen area (UNFPA, 2009). The fertility rate in rural areas is 2.28% or even higher in remote areas, while in urban areas it is only 1.73% (UNFPA, 2009). Barriers for ethnic minority women's access to health care services include geographic distance, financial constraints for food, transportation and services, and the gender of hamlet health workers (when hamlet health workers are men, women feel shy asking for help). For example, 56.1% of women in mountainous areas give birth at home and have relatives, neighbors, or friends assist in the delivery (CCIHP, 2009).
While the average nationwide rate of women having an antenatal examination three times during pregnancy is 86.5, this rate is only 45% or even lower in ethnic minority women (UNFPA, 2007). The maternal mortality rate in ethnic minority women is 10 times higher (410/100,000) than that of the population in the Red River Delta (40/100,000) (Tran, 2005).
National studies show that young girls are sexually active earlier. In the past five years, the age at which girls first had sex declined from 19.5 to 18 years old. However, only 47% of them actively search information about preventing pregnancy and nearly 65% of them still feel shy about using condoms. Further, only about 18% of female adults have the correct knowledge about when they can conceive during their menstrual cycle. There is a big gap between rural (17%) and urban areas (23%) as well as between ethnic minorities (12%) and Kinh/Hoa (19%) (Ministry of Health, 2010).
Female adolescents and adults migrating from rural to urban areas are at high risk of being trafficked and sexually abused (CISDOMA, 2008; Rushing, 2006). Migrant women working in factories, entertainment establishments, and as sex workers are at high risk of being abused or, acquiring HIV and other sexually transmitted diseases (STDs) (Ngo, 2010; Nguyen et al., 2010). Their access to services is limited. Difficulties in registering residence, the economy, and marginalization have made many migrant women hesitant about going to health clinics (CISDOMA, 2008; UNFPA, 2010).
The instance of HIV infection is increasing among women. It is estimated that there are about 48,000 pregnant women with HIV in 2012 (Ministry of Health, 2009). A study of 22 provinces in 2009 showed that 84.3% of women living with HIV have HIV-positive lovers, while this rate is only 53% in men. This study also shows that HIV- positive women have limited knowledge regarding their sexual and reproductive health and they are at high risk of sexual and reproductive health problems. In fact, 24% of them got pregnant even after they knew about their HIV status. Within that group, 31% got pregnant because they did not have access to contraceptive services. In the group of pregnant women, 61% of them had an abortion and 13% had abortions at least twice. 9% of them gave birth because they could not access abortion services; 24% of them had symptoms of STDs in the 12 months before the study (Khuat et al., 2009). Other studies also show that women with HIV suffer from the high pressure to have a son (Hoang et al., 2009; Pauline et al., 2008)
Disabilities greatly affect women's families and their sexual lives. Women account for only 30% among married people with disabilities (Duong & Hong, 2008). Stigma and discrimination are the main reasons for women with disabilities not to be able to fulfill their sexual and reproductive health and rights (Hoang et al., 2010; Do, 2009). Health staff and clinics are often not friendly and sensitive toward people with disabilities. Sexual and educational materials on sexual and reproductive health for people with disabilities are rare or nonexistent (CCIHP, 2010).
There are gaps in the policies. Poor women are often included in them, but some groups, such as migrant women, women who are victims of domestic violence, women living and affected by HIV, women with disabilities, ethnic minority women, and women in same sex relationships, are often neglected in current laws and policies on sexual and reproductive health.
In conclusion, while Vietnam has made important progress toward achieving the objectives outlined in its Plan of Action, the neglect of key disadvantaged groups of women has hindered this national achievement. The sexual and reproductive health risks that these at-risk women are facing also increase the gender gap. Gender inequality significantly contributes to increasing their risk. Thus, several problems still need to be addressed in order to improve their sexual and reproductive health rights effectively: issues related to gender, the denial of their sexual and reproductive rights, and the lack of sensitive and friendly health services that can respond to their specific needs.
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