Sub-optimal use of ultrasound examinations may result in underperformance of Vietnamese maternity care – A qualitative study of midwives’ experiences and views

Highlights

• Obstetric ultrasound was experienced as a highly valued tool in maternity care.

• Replacing antenatal care with ultrasound examinations was reported as troubling.

• Use of non-medical ultrasounds was perceived as a generally accepted phenomenon.

• Private care could be sought to receive the preferred maternal services.

Abstract

Objective

To explore Vietnamese midwives’ experiences and views on the role of obstetric ultrasound in relation to clinical management, including ethical aspects.

Methods

Using a qualitative design, content analysis of focus group discussions with midwives (N = 25) working at Departments of Obstetrics and Gynecology at three hospitals in urban, semi-urban and rural parts of Hanoi were performed.

Results

Obstetric ultrasound was reported as being a highly valuable tool, although replacing ordinary antenatal care surveillance with ultrasound examinations and misuse of ultrasound without medical indication was perceived as troubling. Participants generally viewed the fetus as a human being already at an early stage of pregnancy. However, when complications occurred, the pregnant woman’s health was mostly prioritised.

Conclusion

Although the use of ultrasound has many benefits during pregnancy, replacing ordinary antenatal care surveillance with ultrasound examinations and misuse of ultrasound without medical indication is concerning and needs to be addressed. There is also a need to communicate the benefits of adequate antenatal care to pregnant women and caution about the non-beneficial use of repeated ultrasound examinations without medical indication. Additionally, non-medical ultrasounds consume limited healthcare resources and its use needs to be better regulated in Vietnam.

Introduction

Ultrasound is widely used in pregnancy but the recommendations for the provision of routine ultrasound services vary between countries [1], [2], [3]. Since 2016, the World Health Organization (WHO) recommends one ultrasound examination before 24 weeks gestation to estimate gestational age, improve detection of multiple pregnancies and fetal anomalies, reduce post-term induction of labour and to improve the woman’s pregnancy experience [4]. Routine obstetric ultrasound performed by a skilled provider may also facilitate timely and appropriate management of pregnancy complications in the presence of a well-functioning referral process [4]. In Vietnam, ultrasound is a central part of maternity care [5]. Although the “National guidelines for reproductive healthcare” in Vietnam recommends three ultrasound examinations during pregnancy at 11–13, 20–24 weeks and 30–32 gestational weeks respectively [6], women in Hanoi report an average of more than six ultrasound examinations during pregnancy [5]. It has been reported that pregnant women request repeated ultrasound examinations for reassurance about fetal wellbeing [5] which may, depending on the setting, add significant costs both for women and the healthcare system while not improving pregnancy outcomes [7]. The development of private healthcare and easy access to obstetric ultrasound in Vietnam have also helped to cater to this demand [8].

In general, antenatal care (ANC) provides a platform for important healthcare functions that contribute to safer deliveries and reduction of obstetric complications as well as decreasing maternal and neonatal mortality [4], [9]. In 2016, WHO updated their recommendations to the ‘2016 WHO ANC model’ with a minimum of eight ANC contacts and the first contact before 12 weeks’ gestation [4]. The new recommendations by WHO are intended to be adapted to the model of care suitable for different countries, local contexts and the individual woman [4]. The “National guidelines for reproductive healthcare” in Vietnam last updated in 2016, recommend, for uncomplicated pregnancies, at least one ANC contact in the first and the second trimester, and two contacts in the last trimester [6]. In addition to ultrasound examinations and general examinations such as weight and blood pressure, assessment of the size of the uterus and the frequency of fetal heartbeats are also recommended during pregnancy. Other recommendations are tests for detection of protein in the urine, hemoglobin, blood glucose, HIV, syphilis and hepatitis [6]. In 2014, 74% of women received at least four ANC visits but there were considerable differences within the country [10].

Vietnam has undergone a major transformation over recent decades through economic and political reforms, from being one of the poorest countries in the world to becoming a lower middle income country by 2010 [9]. During the early 1990s, a social health insurance (SHI) scheme was introduced [11] which became compulsory in 2014 under the revised Health Insurance Law [12]. In 2017, the SHI covered more than 86% of the population [13]. For employees, the premium for SHI is 1.5% of the monthly salary and an additional amount, 3% of the monthly salary, is paid by the employer. Residents with a low income have a 100% subsidy for the SHI, which is paid by the government [14]. The SHI covers costs for regular ANC and delivery provided at the primary healthcare level. The insurance also covers costs for patient transfer to higher healthcare level in case of pregnancy or delivery complications [15]. As a result of these reforms, the maternal mortality has decreased from 139 to 54 deaths per 100,000 live births between 1990 and 2015 [11]. Commonly, urban pregnant women attend ANC at higher level hospitals and private clinics because of their perceptions of provision of better quality of care at those facilities, resulting in increased out-of-pocket payment [16]. The SHI does not cover antenatal tests and diagnosis for non-treatment purposes, in addition to the regular pregnancy check-ups [15]. However, obstetric ultrasound examinations are affordable for most urban pregnant women [17].

The public healthcare system is divided into four levels; commune, district, provincial and central levels. At the commune level, primary healthcare is offered by commune health centres [18] where ANC, normal deliveries, postnatal care and immunisation services are provided. At district level, ANC, delivery care and neonatal care are provided by district hospitals. The provincial hospitals provide general and specialised care and receive referrals from lower levels of health facilities [19]. At the top, there are national hospitals providing highly specialised care and modern technologies as well as technical support for lower levels [20]. Most Vietnamese women are giving birth in public hospitals [10]. During pregnancy, women are using different public and private health facilitates for ANC and ultrasound examinations respectively, contributing to lack of continuity of care [5], [21]. Physicians are the main providers of ANC in Vietnam, with approximately 89% of women receiving at least one ANC contact with a physician [10]. A third of pregnant women receiving ANC have reported that the ANC surveillance was delivered by a midwife or a nurse. Of these women, two thirds have reported that they also received ANC from a physician [10], [21]. Midwives work tasks in ANC often include monitoring and assessment of pregnant women, counselling on health education and organising of the individual healthcare plan, while physicians are responsible for the overall examinations and treatment [22].

This study is a part of the CROss Country UltraSound study (CROCUS) aiming to explore midwives’ and obstetricians’ experiences and views on the use of obstetric ultrasound in low, middle and high-income countries. Obstetric ultrasound is a well-integrated tool in maternity care in Vietnam but studies have shown that there is significant overuse of ultrasound resources for non-medical indications within the country [5], [23]. Our previous CROCUS publication on Vietnamese obstetricians’ views on obstetric ultrasound, shows that ultrasound gives rise to many ethical dilemmas such as commercialisation and sex selection, despite it being a highly valued tool during pregnancy [24]. Vietnamese midwives have an important role in maternity care, however there is a lack of studies investigating their views of obstetric ultrasound. To fill this knowledge gap, the aim of this study was to explore Vietnamese midwives’ experiences and views on the role of obstetric ultrasound in relation to clinical management, including ethical aspects.