Our study results indicate that none of the three VFP dimensions was significantly associated with the odds of having an induced abortion nor repeated abortions. The proportion of women who ever had one abortion and who ever had more than one abortion did not differ significantly among women receiving counseling, information about modern methods, and access to available methods. These findings are not supportive of the mainstream opinion that receipt of VFP services will influence the use of preferred contraceptives and thus will reduce abortion incidence [20
]. However, these findings imply that women in general are still receiving poorly performed family planning counseling and inadequate information/communication about their method of choice, not to mention facing limited contraceptive access/availability.
Accessibility affects nonusers of modern methods and current users of traditional methods in Vietnam [8
]. When women who preferred to buy contraceptive pills or condoms instead of IUDs did not receive adequate counseling on how to use oral pills nor adequate information about their immediate and long-term side-effects, they did not feel comfortable buying their preferred methods in the open market and thus they continue to use IUD or chose traditional methods. Figure
evidences the fact that current use of IUD is still the predominant modern method in Vietnam. In addition, many Vietnamese family planning providers are still holding the same mindset planted by the IUD campaigns in the 1980s. They did not deliver VFP services seriously, and persisted in treating IUD as the method of attention instead of optimizing access to other modern methods. The attitude of family planning providers certainly will affect future VFP counselling and communication strategies. Policy-wise, increasing the availability of modern contraceptive methods other than IUDs, as well as providing quality information, will increase the use of effective modern family planning methods and decrease the use of traditional methods, leading to change the paradoxical situation of high use of contraceptives and high abortion in Viet Nam.
Performing VFP needs more time than the usual 3–5 minutes of provider-client interaction that is typical at the primary care level. A prerequisite of applying additional services such as VFP is a well-motivated workforce, according to a joint-study conducted by researchers from the Hanoi School of Public Health and the Royal Tropical Institute (KIT) in 2003 [21
]. It is noteworthy that the data for the Dieleman et al. 2003 study were collected in two provinces adjacent to Thai Nguyen province (where data for our study were collected). This 2003 motivation study was the first of its kind that looked at rural health workers’ perceptions with respect to job motivation at commune and district health centers in rural areas of northern Vietnam [21
]. They found that motivation is influenced by both financial and non-financial incentives (such as appreciation by supervisors, colleagues, and the community). Low salaries, difficult working conditions, and lack of communication skills were noted as discouraging factors. Health workers also tend to perceive supervision as control. In addition, selection for training is seen as opaque and unequal, and performance appraisal is not useful [21
]. Although the Ministry of Health in Vietnam prioritizes development of a public health network to provide good quality services including family planning, their findings showed that there were still insufficient qualified and motivated human resources in rural areas.
Motivation, or an individual’s degree of willingness to exert and maintain an effort to achieve certain organizational goals, is a complex concept. It needs supervision, performance appraisal, career development, and appropriate training. Not all trainings are adequate and casual supervision visits achieve little. Apparently, in-service trainings by vertical health programs (such as the voluntary family planning dimensions) do not count as significant credit points in a health worker’s curriculum vitae; in fact, they tend to participate because these trainings pay per diems, so they are perceived merely as an income opportunity.
To some extent, the motivational problem found in performing voluntary family planning dimensions is not exclusive to Vietnam. A recent study (2011) that systematically reviews 80 studies from Africa and Asia and the Pacific on quality and performance of private and public ambulatory health care in low- and middle-income countries (published between 1970 and April 2009) concluded that raising the quality of care is a long-term effort. The government has an important role, but supervision, auditing with feedback and quality training have been found to be an effective combination [22
In order to strenghthen current VFP services in Vietnam, new performance-based measures should be used to record the number of clients counseled and the number of clients given adequate information about IUD and other modern methods. Monitoring of these new measures should be recorded and reported in order to increase the knowledge and availability of all modern methods, not only IUD. Eventually, this will reduce the number of nonusers of pills and condoms and reduce the number of current users of traditional methods. More in-depth training materials about the three VFP dimensions should be incorporated in the pre-service training curricula for students of medicine, midwifery academics, and nurses. The government’s women’s empowerment program should participate in creating messages that encourage women to obtain information about efficacy of a method before choosing one. This change in orientation should make use of the national standards and guidelines on counselling to protect vo-luntarism in family planning, and will contribute to the government’s efforts to reduce abortion incidence, which will eventually change the paradoxical situation of high use of contraceptives and high abortion in Vietnam.
Our study is limited because it is a cross sectional design; therefore caution must be exercised in the interpretation of the observed associations between induced abortion and VFP measures. In addition, data did not include unmarried women, whose induced abortion behaviors could be different from married women. There was also a possibility that induced abortions among the younger maternal age (18–24) were under-reported because an abortion before the first birth was viewed as disgraceful (implying out-of-wedlock pregnancy). In spite of these limitations, this study is the first one to assess the association between VFP dimensions and induced abortion in Vietnam. Considering that our community-based survey yielded close to a 95% response rate, and the study sample was a representative sample of married women aged 18–49
years, selected using a two-stage cluster sampling technique, our findings can be generalized to the population of women aged 18–49
years in Thai Nguyen province and to the wider region of northern Vietnam with the important policy implication for improving family planning services in the country.