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Health Professionals' Experiences and Views on Obstetric Open access Original research BMJ Open: first published as 10.1136/bmjopen-2019-031761 on 22 September 2019. Downloaded from Health professionals’ experiences and views on obstetric ultrasound in Vietnam: a regional, cross- sectional study Sophia Holmlund, 1 Pham Thi Lan,2 Kristina Edvardsson,1,3 Ho Dang Phuc,4 Joseph Ntaganira,5 Rhonda Small,3,6 Hussein Kidanto,7 Matilda Ngarina,8 Ingrid Mogren3 To cite: Holmlund S, Lan PT, ABSTRACT Strengths and limitations of this study Edvardsson K, et al. Health Objectives Obstetric ultrasound is an important part professionals’ experiences and of antenatal care in Vietnam, although there are great ► The study questionnaire was developed based views on obstetric ultrasound differences in access to antenatal care and ultrasound in Vietnam: a regional, cross- on the results from earlier qualitative studies per- services across the country. The aim of this study was sectional study. BMJ Open formed with obstetricians/physicians and midwives/ to explore Vietnamese health professionals’ experiences 2019;9:e031761. doi:10.1136/ nurses in six different countries (the CROss Country and views of obstetric ultrasound in relation to clinical bmjopen-2019-031761 UltraSound study). management, resources and skills. ► The strengths of this study include participants of ► Prepublication history for Design A cross-sectional questionnaire study was different health professional categories recruited this paper are available online. performed as part of the CROss Country UltraSound study. To view these files, please visit from different levels of the healthcare system in ur- Setting Health facilities (n=29) in urban, semiurban and the journal online (http:// dx. doi. ban, semiurban and rural areas of Hanoi. rural areas of Hanoi region in Vietnam. org/ 10. 1136/ bmjopen- 2019- ► The research team comprised two Vietnamese re- Participants Participants were 289 obstetricians/ 031761). searchers familiar with the setting and the health- gynaecologists and 535 midwives. care system, which strengthens the interpretation Received 20 May 2019 Results A majority (88%) of participants agreed that of data. Revised 26 August 2019 ‘every woman should undergo ultrasound examination’ ► One limitation of this study may be the translation Accepted 29 August 2019 during pregnancy to determine gestational age. of the questionnaire from English to Vietnamese; Participants reported an average of six ultrasound http://bmjopen.bmj.com/ however, measures to reduce the risk of losing the examinations as medically indicated during an intended meaning of questions and statements were uncomplicated pregnancy. Access to ultrasound at implemented. participants’ workplaces was reported as always available ► Since previous studies within this research domain regardless of health facility level. Most participants are lacking, the power calculation was based on as- performing ultrasound reported high-level skills for fetal sumptions of proportions for one outcome variable heart rate examination (70%), whereas few (23%) reported in relation to one background variable, and may being skilled in examination of the anatomy of the fetal therefore mean uncertainty of the required study heart. Insufficient ultrasound training leading to suboptimal sample. pregnancy management was reported by 37% of all on September 26, 2021 by guest. Protected copyright. participants. ‘Better quality of ultrasound machines’, ‘more physicians trained in ultrasound’ and ‘more training for health professionals currently performing ultrasound’ were decreased maternal and neonatal morbidity reported as ways to improve the utilisation of ultrasound. and mortality.1 Timely and appropriate Conclusions Obstetric ultrasound is used as an integral evidence-based practices in ANC including part of antenatal care at all selected health facility levels health promotion, screening and diagnosis, in the region of Hanoi, and access was reported as and prevention for diseases can save lives.2 high. However, reports of insufficient ultrasound training Since 2016, WHO recommends a minimum resulting in suboptimal pregnancy management indicate of eight ANC contacts during pregnancy and © Author(s) (or their a need for additional training of ultrasound operators to employer(s)) 2019. Re-use improve utilisation of ultrasound. one ultrasound examination before 24 weeks permitted under CC BY. of gestation. The aim of the recommenda- Published by BMJ. tion of an early ultrasound scan is to estimate For numbered affiliations see BACKGROUND gestational age, improve detection of multiple end of article. Sufficient antenatal care (ANC) services pregnancy and fetal anomaly, reduce induc- Correspondence to and skilled birth attendance are important tion of post-term pregnancy, and improve 2 Sophia Holmlund; factors contributing to safer deliveries, women’s pregnancy experience. Ultrasound sofia. holmlund@ umu. se reductions in obstetric complications, and is an important part of ANC in high-income Holmlund S, et al. BMJ Open 2019;9:e031761. doi:10.1136/bmjopen-2019-031761 1 Open access BMJ Open: first published as 10.1136/bmjopen-2019-031761 on 22 September 2019. Downloaded from countries,3 and clinical trials show that ultrasound may MATERIALS AND METHODS improve management and pregnancy outcomes in the The Vietnamese setting developing world.4 Since 2010, Vietnam has been classified as a lower The utilisation of reproductive health services in middle-income country and has undergone substan- Vietnam has substantially increased over recent decades, tial economic development in recent decades.1 The but there are still inequities in the country.5 Low educa- maternal mortality rate has decreased from 139/100 000 tion, poverty, ethnic minority status6 and living in rural in 1990 to 54/100 000 live births in 2015.15 Most inpa- areas are factors associated with decreased access to tient healthcare is provided by public hospitals, but for reproductive health services.5 Ultrasound has become a outpatient care private clinics account for a large number central tool in ANC services in Vietnam.7 Currently the of patients.16 Vietnam is divided into 63 provinces, 698 Ministry of Health in Vietnam recommends at least four districts and 11 121 communes.17 In each commune, a ANC visits,8 in accordance with the previous recommen- village health worker (VHW) provides health promotion, dation by WHO.9 Additionally, three ultrasound examina- immunisation and nutrition services, and attends births 18 tions are recommended during pregnancy, in gestational in remote areas. At the community health centre level, weeks 11–13, 20–24 and 30–32.8 In 2014, more than 70% a midwife or an assistant doctor is in charge of maternal of pregnant women in Vietnam received at least four ANC health services, and provides ANC, assists normal delivery, visits.10 However, almost half of these women reported and provides postnatal care, immunisation services and not having urine or blood samples taken or blood pres- supervision of the VHW. At the district level, ANC, sure measurement done during their last pregnancy.10 delivery care including caesarean sections and newborn 18 The private health sector is a continuously growing part care are provided at hospitals, while maternity homes 16 18 of healthcare services in Vietnam, especially for provi- deliver basic prenatal and delivery services. Provincial sion of legal abortion services and obstetric ultrasound hospitals provide more specialised healthcare, and refer- examinations.11 Limited salary for physicians creates rals from lower healthcare levels to provincial level are incentives for both public and private practitioners to undertaken if complications occur during pregnancy or 18 search for additional income through provision of these delivery. At the top of the healthcare system, there are services.12 13 Commercialisation of ultrasound services several national hospitals providing specialised care and 16 has led to urban Vietnamese women having an average of receiving referrals from lower levels. more than six ultrasound scans during pregnancy, which is a high number of examinations from an international Study design perspective.12 14 This cross-sectional study used a questionnaire to investi- gate a number of research questions related to obstetric ultrasound with obstetricians/gynaecologists and Study rationale midwives providing pregnancy, delivery and postpartum http://bmjopen.bmj.com/ Few studies have investigated the use of obstetric ultra- care to women in the region of Hanoi, Vietnam. sound in Vietnam from health professionals’ perspectives, although ultrasound is frequently used during pregnancy. Sampling This study serves to fill a knowledge gap and can benefit Owing to the lack of findings from similar studies, a authorities in their work to further develop education sample size of 290 obstetricians/gynaecologists and a and improvement of guidelines on obstetric ultrasound corresponding number of midwives (n=290) was calcu- use. This study is part of the CROss Country UltraSound lated based on plausible estimations of prevalence of study (CROCUS) investigating health professionals’ background characteristics and outcome variables. The on September 26, 2021 by guest. Protected copyright. experiences and views of the use of ultrasound in high-re- calculation was based on the outcome requiring the source, middle-resource and low-resource countries. largest sample size, ‘every woman should undergo ultra- sound examination in pregnancy to determine gestational Aims age’,
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