Fertility and Family Planning in Vietnam James Allman; Vu Qui Nhan; Nguyen Minh Thang; Pham Bich San; Vu Duy Man Studies in Family Planning, Vol. 22, No. 5. (Sep. - Oct., 1991), pp. 308-317. Stable URL: http://links.jstor.org/sici?sici=0039-3665%28199109%2F10%2922%3A5%3C308%3AFAFPIV%3E2.0.CO%3B2-M Studies in Family Planning is currently published by Population Council.

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REPORTS

Fertility and Family Planning in Vietnam JamesAllman, Vu Qui Nhan, Nguyen Minh Thang,

Pham Bich San, and Vu Duy Man

This report provides the first reliable statistical data on fertility patterns and the family planning program in the Socialist Republic of Vietnam. Findings are fvom the 1988 Demographic and Health Survey of Vietnam and the 1989 census survey. The data show that the total fertility rate has declined from over 6 children per woman in the early 1970s to under 4 in the later 1980s. Contraceptive prevalence for modern methods is estimated at 37 percent among married women of reproductive age in 1988. The average duration of breastfeeding is over 14 months; marriage is relatively late. The IUD is the most common contraceptive method and abortion is widespread. The major factors likely to influencefertility and family planning in the future are the government's population policy, improved access to modern methods of contraception,and the institution of new economic policies that are I N FAMILY PLANNING 1991; 22,5: 308-3171 currently under way in Vietnam. (STUDIES The demography of Vietnam has been the subject of several studies. These studies relied primarily on 1979 census data, historical materials, and a broad array of disparate and sometimes somewhat contradictory data culled from field visits (Fraser, 1985 and 1988; and Jones, 1982, who both visited Vietnam), and the monitoring of newspapers, government documents, and radio reports (Banister, 1985and 1990).These analyses, because of their relatively thin data base, leave the reader unclear as to whether fertility in Vietnam is, in fact, falling; what the impact of the national family planning effort has been; how great population growth is; and what mortality levels are. Until recently, "the lack of reliable statistical data makes firm conclusions on demographic trends and on the possible impact of population limitation virtually impossible" (Nguyen Huyen Chau, 1988). Fortunately, several recent data sets allow us to examine fertility and family planning trends during the last 15 years with much greater clarity. This report draws primarily on data from the 1988Demographic and Health

James Allman, Ph.D. is chief technical adviser to the National Committee for Population and Family Planning (NCPFP),Hanoi. He can be reached c/o UNICEFIHanoi. V u Qui Nhan, M.D. and Nguyen Minh Thang, Ph.D, are members of the NCPFP. Pham Bich San, Ph.D. is head of the Population Unit, Institute of Sociology, Hanoi. V u Duy Man, Ph.D. is Deputy Director of the Institute of Computer Sciences, Hanoi.

308 Studies in Family Planning

Survey and the 1989 Five Percent Population Census Sample, and on information gathered by the first author while traveling and living in Vietnam throughout most of 1989-91. After providing some background on Vietnam and briefly reviewing data sources, the report looks at levels and trends in fertility and at some of the factors-including marriage patterns, desired family size, infant mortality levels, and breastfeeding patterns-that determine the current situation. It then examines knowledge and use of contraception among the Vietnamese and measures the impact of the national family planning program. Factors that are likely to influence fertility and family planning trends in the future are also discussed.

Background Since the reunification of North and South Vietnam in 1975,the Socialist Republic of Vietnam has given priority to reducing population growth and extending the coverage of family planning services throughout the country, a policy that had been applied only in the North beginning in 1963 (Nguyen Huyen Chau, 1988). Soon after unification, the government carried out major resettlement efforts to new economic zones, for both economic and political reasons (Desbarats, 1987; Thrift and Forbes, 1986). Social development efforts, such as raising literacy levels, extending basic education and health services, and

mobilizing the population in mass organizations, were initially very successful. Attendance at primary school has been almost universal, with 84 percent of women aged 10 years and older literate in 1989, according to the census (Government of Vietnam, 1990). The network of health care institutions is extensive: Almost all of Vietnam's over 8,000 communes have a health center and a nearby district- or provincial-level facility for referral. Immunization coverage is high, major efforts have been devoted to the control of diarrheal diseases, and health education is being expanded. In 1988,Vietnam had 22,800 doctors, giving a ratio of 3.4 doctors for every 10,000 inhabitants (Abbatt,1990).The Vietnamese Women's Union and various other mass organizations continue to mobilize the population in support of health and educational activities. However, recent reviews of the social sectors point to serious problems arising from low levels of quality in both education and the health delivery system (Abbatt, 1990; Allman, 1990,1991a, and 1991b; Schofield, 1989; Segall, 1988; UNDP, 1990; Vogel, 1987; UNICEF, 1990). The need to reform, improve, and upgrade staff and institutions is of great concern to policymakers and the public, particularlybecause government resources for social services are being reduced. For about 10 years after reunification, Vietnam's economic policies, which stressed agrarian reform through cooperatization as well as the expansion of centrally planned, state-run industries, did not produce significant improvements in the standard of living. Starting in 1975, the economy was very tightly controlled, and little scope for private initiative was allowed. Food production suffered greatly, private business was suppressed, and the country experienced several very difficult years (Nguyen Xuan Oanh, 1988;Thrift, 1987).This situation encouraged extensive out-migration: Close to 1.5million people have left the country since 1975because of poor economic conditions, military operations, and large-scale labor export to the USSR and Eastern Europe (Le Phuong, 1990a). The government's rigid economic policies were seriously questioned at the Sixth Party Congress in December 1986. Economic renewal-"doi moi"-became the new approach (Huynh Kim Khanh, 1988). Since then, the government has been reversing past policies with generally positive results (devylder and Fford, 1989).Nguyen Xuan Oanh, a Harvard-trained, high-level economic adviser, characterizes the new approaches as "a complete restructuring of economic thinking and a revolution in management" (Nguyen Xan Oanh, 1988).In 1989, Vietnam became the world's third largest exporter of rice, industrial production was up, tourism grew, and numerous joint ventures were developed with foreign firms (Hiebert, 1990).While still one of the poorest countries in the world, with a per capita GNP of under $200 in 1990,

Vietnam appears to be entering into a period of economic development (UNDP/State Planning Committee,l990). Nevertheless, serious disagreement exists about Vietnam's economic prospects and the current state of its economic reforms. Preliminary results from Vietnam's April 1989 census indicate a de jure population of 64.4 million people, a crude birth rate of 31-32 births per 1,000 population, a crude death rate of 8-9 deaths per 1,000 population, and an annual growth rate of 2.2-2.4 percent (Government of Vietnam, 1990).If the present rate of growth continues, the population will reach over 80 million in the year 2000.

Sources of Data The main sources of data on fertility trends in Vietnam are the 1979 and 1989 national censuses, and the 1988 Vietnam Demographic and Healthsurvey (VNDHS).The 1989 census received considerable financial and technical support from the United Nations Population Fund (UNFPA), and is considered to be a major improvement over the 1979 census, which was conducted during very difficult times, with little outside assistance and with long delays in the presentation of results. This report will refer primarily to the 1989Census Population Five Percent Sample, which was designed to provide high quality data on standard demographic indices. The first results were released by the government in March 1990. The 1988 VNDHS was carried out by the National Committee on Population and Family Planning in conjunction with several research institutes in Vietnam. The Population Division of the United Nations Economic and SocialCommission for Asia and the Pacific provided technical assistance. Although not a part of the program conducted by the Institute for Resource Development (IRD) with USAID support, the survey in Vietnam closely followed procedures used by IRD as well as those developed by the World Fertility Survey (WFS)program. Foreign advisers with WFS experience and familiarity with the DHS program provided technical assistance to the Vietnamese team. A total of 4,807 households and 4,172 eligible women aged 1 5 4 9 were interviewed. A preliminary report was issued by the government in November 1989; a detailed report came out in November 1990.

Fertility Levels Table 1 indicates that total fertility rates (TFRs)have been declining slowly since the 1970s. Although still not low, the TFR in Vietnam as a whole has declined from over 6 children per woman to around 4 in 20 years. This decline,

Volume 22 Number 5 September/October 1991 309

Table 2 Percent distribution of women aged 15-49 according to current marital status, by current age, Vietnam, 1988 VNDHS

Table 1 Estimates of total fertility rates for Vietnam, selected vears and sources Years 1969-74 a 1974-79 1983-87 198647 1987-88 -

North Vietnam

South Vietnam

Urban

5.7 4.7 4.7 4.3 na

6.6 5.1 4.7 4.0 na

na na 2.7 2.2 na

Total Rural Vietnam na na 5.2 4.6 na

6.1 4.8 4.8 4,2 4.0

-

Note: na = not available.

bNationalCornrnitteefor Populationand

Sources: "ESCAP (1988), pp. 32-33. CGeneralStatisticsOffice (1990).

Family Planning (1990a), Tables3.1 and 3.2.

similar in magnitude to that which occurred in Taiwan between 1950 and 1970 (Greenhalgh, 1988), is evidence that the demographic transition is clearly under way in Vietnam. The considerably higher TFRs estimated for South Vietnam compared with North Vietnam for the 1969-74 period is not surprising, given the fact that the North had promoted family planning since 1963and had made major efforts at social development since the beginning of the nationalliberationmovement in 1945(Beresford,1988; Chaliand, 1968; Eisen, 1984; Ruscio, 1989).However, the fact that the TFR is currently lower in the South is unexpected, especially because levels of education are higher and the family planning program is much more developed in the North. Other factors, some of which we will consider below, probably play a role.

Fertility Determinants There has been no research on fertility determinants in Vietnam, but the conceptual model proposed by Bongaarts (1982) suggests that the major variables determining fertility levels are nuptiality patterns, prolonged breastfeeding, and the use of traditional and modern contraception. Since the 1979 census did not ask questions on marriage, the only nationally representative data come from the 1988 VNDHS and the 1989 census, which both provide data on marriage patterns. Table 2 shows that few Vietnamese women under the age of 20 enter a union, and only half of those between the ages of 20 and 24 are currently married. The age at marriage has been relatively late among the last few cohorts of women. The 1988 VNDHS data indicate that only women over the age of 45 had a median age at marriage under 20; for the cohorts aged 25-29 to 4044, the median age at marriage was over 21 years. For women aged 2529 in 1988, the median age at first marriage in urban areas of the North and the South was over 24, while it was 21 for rural women in the North and 20 for rural women in the South. The singulate mean age at marriage for women

310 Studies in Family Planning

Age group

Divorced or Neverseparated married Married Widowed

Total

15-1 9 20-24 24-29 30-34 35-39 40-44 45-49

100

100

100

100

100

100

100

All

100

Note: Dash (-)=less than one percent.

Source: National Committee for Populationand Family Planning (l990a), Table 2.1.

calculated from these data is 23.5 years, slightly higher than the 23.1 years calculated from 1989 census data. In the past, polygamy was common in rural areas, women had few rights, prostitution was widespread in the South, and there were large numbers of illegitimate children. The American presence left between 40,00070,000 Amerasian children (Goose and Horst, 1988).The situation changed with the liberation of the North in 1954 and the unification of the country under a socialist regime in 1975. Age at marriage was legislated (18 for women and 20 for men), economic conditions made marriage difficult, and a "marriage squeeze," due to excess male mortality during the war, contributed to later ages at marriage and the fact that only 60 percent of women of reproductive age were currently married in 1988 (see Table 2). Because of the changes in marital patterns in Vietnam during- the last few decades, additional research is needed to elucidate the dynamics of family formation and the relationship between nuptiality and fertility. Moreover, it is uncertain what impact recent economic liberalization and the abolition of the cooperative system will have on marriage and fertility patterns in the future. The 1988 VNDHS elicited information on breastfeeding, but data on postpartum amenorrhea were not collected. The average duration of breastfeeding is 14.5 months in Vietnam, with little variation by residence and some differences in length by education. These findings are in accord with other studies (Nguyen Thu Nga and Weissner, 1986; UNICEF, 1990). Infant Mortality As Table 3 shows, both the 1989 census and the 1988DHS indicate a pattern of low infant mortality rates (IMR).As with all retrospective surveys that have relatively small sample sizes and are subject to sampling error, theVNDHS may underestimate the actual IMR; estimates based on the 1989 census are probably more realistic and are currently the best estimates available.

Table 3 Infant mortality rates (per 1,000 births), by selected years and sources, Vietnam, 1983-89 Year and source

Table 4 Percentage of currently married women who want no more children, by selected background characteristics, according to number of living children, Vietnam, 1988 VNDHS Number of living children

Area

Characteristic

North Vietnam South Vietnam Vietnam (all)

Residence Urban Rural Region North South Education Illiterate Literate a Primary Secondayi

--

-

-

Note: na = not available.

National Committee for Population and

Sources: a UNICEF (1990), p. 17. 'General StatisticsOffice (1990).

Family Planning(1990a), Tables6.1 and 6.2.

Earlier low estimates of the IMR were greeted with considerable skepticismby those concerned with population, health, and development in Vietnam. How could such a poor, underdeveloped country with a per capita GNP of under $200 per annum have an IMR of around 50 per 1,000 births? An answer might be found in the very high level of education attained by women in Vietnam, the government's stress on universalizing communitylevel primary health care, economic equity that assures a minimal living to all, and the major advances in women's status that followed independence and national liberation. Other poor areas (for example, Kerala in India, and China) have been able to lower the IMR by focusing on education, health, and improvements in women's status (Halstead et al., 1985; Morley et al., 1983). As Cleland and van Ginneken (1988)show in a recent review of the relationship between maternal education and child survival in developing countries, "the interrelationship between maternal education, health service provision and childhood mortality is complex and variable." However, for a country like Vietnam, where the government has stressed both expansion of education and health services, "the key to low mortality at the societal level may be a synergy between mass education and egalitarian policies which lead to demands for a health service that caters to the needs of all" (Cleland and van Ginneken, 1988). Family Size and Gender Preferences The 1988VNDHS found that Vietnamese women desired an average total family size of 2.6 children (2.7 children among rural women and 2.3 children among urban women). Desired family size was higher in the South (averaging 2.8 children), than in the North (2.41,and among illiterates (over 3), compared with women with some education. Preferred family size is still above the government's two-children family norm. As Table 4 shows, 60 percent of currently married women want no more children. There was no urban-rural difference, but women in the South were slightly less likely to say they wanted no more children than were those in the North. Women with a primary or higher education

0

1

2

3

4+

All

Total

his categoy contains people who did not attend formal school, but who probably learned to read and write during one of the government's literacy campaigns. Source: National Committeefor Populationand Family Planning(1990a), Table 5.3.

were more likely than those with less or no education to say they wanted no more children. Son preference was not studied in the survey, but there is a tradition of preferring boys to girls in Vietnam, as in other Sinic populations (Greenhalgh, 1988).Interviews during field visits suggested that the decision of couples to have more than the two children allowed by government population policy was often related to wanting to have at least one boy in the family (Allman, 1990). Knowledge of Contraception The 1988 VNDHS collected information for all women aged 15-49 concerning their knowledge of both modern and traditional methods of fertility regulation. Knowledge of methods was elicited using the standard approach developed by the WFS and DHS programs. Thus, spontaneous answers were elicited, then respondents were asked if they had ever heard of specific methods that they had not mentioned spontaneously. The findings in Table 5 indicate high levels of awareness of both modern and traditional methods of fertility regulation. Of all the women in the survey, over 90 percent knew or had heard of one or more modern contraceptive methods. It was surprising to find that fewer than half of the women said they knew about oral contraceptives, condoms, and male sterilization.Thislack of knowledge is likely related to the promotion of IUDs to the exclusion of other methods, which had been found in an earlier survey of family planning workers (ESCAP, 1988). It is notable that both menstrual regulation and abortion are cited as fertility regulation methods, in spite of national policy pronouncements stating that these are not family planning methods but are simply methods available to women who wish to terminate an unwanted pregnancy. Volume 22 Number 5 September/October 1991 311

Table 5 Percentage of currently married women aged 15-49 who know about selected contraceptive methods, by age group, Vietnam, 1988, VNDHS Aae - arouo - . Method

15-19 20-24

25-29 30-34 35-39

40-44 45-49

All

Any modern IUD

Pill Condom Female sterilization Male sterilization Rhythm Withdrawal

ity regulation in Vietnam; estimates from local sources indicated that nearly 1 million women had recourse to either menstrual regulation or pregnancy termination in 1988 (NCPFP, 1990). The fairly high TFR-around 4 children per woman in the late 1980s-seems to be out of line with the contraceptive prevalence rate of over 50 percent. Compared with the results Bongaarts (1982)found in a cross-national study of the fertility-inhibiting effects of intermediate fertility variables, one would expect a lower TFR in Vietnam. Several factors may account for the discrepancy: 1 There have been reports of problems and dissatisfaction with the different types of IUDs used in Vietnam (Allen and Nguyen The Thach, 1989; UNFPA, 1989).Method failure withIUDs appears to be high, although it has not been adequately studied.

Menstrual regulation Abortion Source: National Committeefor Populationand Family Planning(1990a), Table 4.1.

2 The interviewers who conducted the 1988 VNDHS were health workers. This situation may have led to a courtesy bias, with women more likely to state that they used contraceptives than was really the case, with a view to pleasing the interviewers.

Contraceptive Prevalence Table 6 provides data on current use of contraceptives among currently married women. Of the Vietnamese women aged 15-44 currently married in 1988,54 percent reported using a contraceptive method. The majority of contraceptors (63percent overall) were using the IUD, the method most actively promoted by the national family planning program. An additional 28 percent of users said they were practicing rhythm or withdrawal. Few women said they used the pill, condoms, or sterilization, undoubtedly because of the limited availability of these methods in Vietnam. Three percent of currently married women said they had had recourse to menstrual regulation and 4 Percent, to abortion. This is undoubtedly an underestimate of the importance of these methods as a means of fertility reguIation in Vietnam, because the questions concerning use of these methods did not ask how many operations the woman had had. Abortion is an important factor in fertil-

3 About 30 percent of reported contraceptive use is of less effective methods-rhythm and withdrawal. The use of such methods, added to problems with the major effective method, the IUD, may lead to an overall low effectiveness of contraceptive use in Vietnam. Findings from micro studies that include information on contraception suggest that contraceptive use is indeed high in Vietnam (Allen and Nguyen The Thach, 1989; Dang Nguyen Anh, 1989).However, there are serious concerns about the low quality of services provided by family planning workers, which could contribute to inefficient method use (ESCAp, 1989).

Table 6 Percent distribution of current use and nonuse of contraceptives among currently married women aged 15-49, Vietnam, 1988 VNDHS

Age group

IUD

Pill

Condom

Female sterilization

Male sterilization

Rhythm

Dash (-) indicatesthat less than one percent use this method Note: Total sample = 3,896. Source: National Committee for Populationand Family Planning (1990a), Table 4.6.

312 Studies in Family Planning

Withdrawal

Any method

No method

ers and 17percentof condom users were supplied through commercial channels, and 5 percent and 20 percent of such users, respectively, were given these methods at other than the basic government health units. Although the use of oral contraceptives and condoms is still insignificant, the findings suggest that a promotion campaign using commercial retail sales might significantly expand the use of these methods.

Sources of Contraceptive Supply The government health service is the major provider of modern methods of contraception in Vietnam. As Table 7 shows, 45 percent of ever-users of clinic methods and 19 percent of users of supply methods are supplied by the commune health center, the basic health unit available in Vietnam's over 8,000 communes. Another 37 percent of users of clinic methods and 24 percent of users of supply methods are supplied at the district hospital, the next institution up in the hierarchy of health care units. The most widely used method, the IUD, is provided to over half of all IUD users at the commune health center. The private sector is beginning to play a role in the supply of methods-32 percent of oral contraceptive us-

Factors Influencing Fertility Regulation Table 8 indicates some of the factors associated with contraceptive use in Vietnam. Current practice of contraception is positively associated with the number of living children that women reported: About 60 percent of wo-

Table 7 Percent distribution of sourcesafor supply and clinic contraceptive methods among ever-users, by method, Vietnam, 1988 VNDHS Clinic methods Supply methods Source Commune health center District polyclinic Province hospital Central hospital Other health institution Private market Other Don't know Total

Female sterilization

Male sterilization

Menstrual regulation

Abortion

Total

na 22 58 18

5 22 33 20

14 58 19 4

4 74 18 4

45 37 12 4

3 na na

-

1

-

6

na

na na na na

-

100

100

100

100

Pill

Condom

Total

IUD

15 24 20 2

22 25 13 2

19 24 16 2

54 33

5 32

13 23

-

1

20 17 na 1

1

na

1 na na 1

100

100

100

100

100

-

-

8 2

2

-

-

2

-

Dash (-) = less than one percent reported.

Notes: na = not applicable. aThe most recent sources are given.

Source: National Committee for Population and Family Planning (1990a), Table 4.9.

Table 8 Current contraceptive use among currently married women 15-49, according to method used, by selected background characteristics, Vietnam, 1988 VNDHS

Characteristic

IUD

Pill

Condom

Female sterilization

33

-

1

3

Male sterilization

Rhythm

Withdrawal

Any method

-

8

7

53

No. of living children 0 1 2 3 4+ Residence Urban Rural Region North South Education Illiterate Literate Primary Secondary+ All

Note: Dash (-) indicates that less than one percent use this method.

Source: National Committee for Population and Family Planning (1990a), Table 4.7.

Volume 22 Number 5 September/October 1991 313

men with two or more children, and ciose to 40 percent of those with one child, were practicing contraception. Urban women use a broader range of contraceptives (IUDs, rhythm, withdrawal, female sterilization, and condoms-in order of use) than do rural women. Women in the North rely more on IUDs than do those in the South, where other methods-particularly rhythm and withdrawal-are used more than in the North. Contraceptive use is lower among the small number of illiterate women than among those with education.

Discussion The data presented here indicate that Vietnam has been in the midst of a demographic transition for the last two decades. Currently, there are relatively low levels of infant mortality and declining levels of fertility. As more data become available from the 1988 Demographic and Health Survey, the 1989 census, the vital registration system, and numerous micro studies recently completed or currently under way, it will be possible to begin to elucidate the determinants of demographic trends. At this point we can only sketch the broad outline. What factors are likely to influence fertility and family planning in Vietnam in the future? Several factors are surely important, including the government's population policy, the measures being taken by the family planning program to improve access to modern methods of contraception, and the success of new economic policies. Let us look briefly at each in turn. Population Policy Government policy to control rapid population growth was first articulated in Vietnam in the early 1960s (Nguyen Huyen Chau, 1988).Results from the 1960 census of North Vietnam made policymakers aware that population growth was greater than desirable. Jones (1982) suggests that "The general awareness of pressure on the land in North Vietnam has no doubt been an important factor leading to unanimity. . . on the need to lower the birth rate." A statement by the government supporting fertility regulation was issued in 1963. The government has repeatedly expressed its commitment to reducing the rate of population growth, and has relied on voluntary family planning to attain that objective. In addition, over the years, and particularly during the last decade, strong statements of support for family planning as being essential for maternal and child health, an important component of improving women's status, and a needed element in population policy have been issued by leading government and party leaders, ministers, and officials at all levels of society. These declarations have been reviewed and well documented in UNFPA publications and in re314 Studies in Family Planning

search articles (Banister, 1989; Fraser, 1988; Jones, 1982; Nguyen Huyen Chau, 1988). The most important recent official population policy statement is the 18 October 1988 Council of Ministers Decree on Population and Family Planning Policies,which was promulgated in 1988 (see Vietnam, 1989 for a translation and commentary). Its goal is to reinforce and strengthen measures to reduce population growth and to ensure that adequate family planning methods are available and used by the population. The National Committee for Population and Family Planning, the ministries, and the people's committees of the provinces and municipalities are charged with responsibility for monitoring and supporting measures to control population growth. Norms are set for the minimum age at first birth (22 years of age or older for women, and 24 years of age or older for men in urban areas and in government service or industry; 19 years or older for women and 21 or older for men in other areas); for the number of children (a maximum of two children for most families, with the exception of members of ethnic minorities and a few other categories who may have three children); and for the spacing of children (generally,the second child should be spaced 35 years after the first). The 30 June 1989 Health Law passed by the National Assembly made legal some of the measures discussed above. In addition, it strongly stressed the fact that individuals must be free to choose the family planning method they wish. Article 2, Chapter 8 of the Family Planning and Mother and Child Health Care Section states that "Institutions of the State, collectives, or individuals must respect everyone's desire to use the method of birth control of their own choosing." Further, Article 4 states that "All acts of preventing or forcing the implementation of family planning are prohibited." Thus, the 1989 National Health Law gives legal force to the individual's right to choose or not to choose to limit births, and provides for recourse to the justice system if there is any attempt to violate this right. People who do not respect the norms for age at marriage, number of children, or child spacing do not appear to suffer serious negative sanctions. Based on field visits, interviews, and discussions with people in the country in 1989-91, the first author got the impression that the Vietnamese family planning program was based on couples' needs and wishes to limit family size. Compliance appears to be voluntary; broad popular support for family planning and concern with the population problem clearly exist. However, there have been some poorly formulated policy declarations, and there is evidence of social pressure put on some couples to conform to policy. For example, there have been cases where government workers who have three children rather than the two allowed do not receive bonuses or standard salary increases.

The National Family Planning Program The Vietnamese National Family Planning Program is a multisectorial effort involving a broad range of ministries and mass organizations that focus on educating, promoting, and encouraging couples to use family planning. Contraceptives are provided through the Ministry of Health's network of health institutions, down to the commune level. This effort has contributed to broad awareness and support for family planning throughout Vietnamese society. The findings from family planning service statistics and the 1988 VNDHS indicate that current use of contraceptives is fairly high. However, there is still considerable scope for improving and expanding contraceptive services, since many women who do not want another birth are not practicing contraception, and recourse to pregnancy termination is frequent. The National Committee for Population and Family Planning (NCPFP)was set up in 1984 to improve coordination among the various related ministries in Vietnam involved in population and family planning activities. The NCPFP advises the government about policy formulation, program development, and coordination of programs. It is also expected to conduct appropriate studies and prepare analyses and policy briefs to carry out these functions. The NCPFP includes members from eight ministries and four mass organizations. A recent national meeting on Population and Family Planning held in Hanoi, 17-18 April 1990, stressed the need for the NCPFP to take a more active role in implementing, managing, and monitoring family planning and population activities.Efforts in this direction are currently under way; there is hope that a more active program that focuses on the distribution of a broader range of contraceptives, supported by more effective IEC efforts in rural communes and districts, will follow. There is an urgent need to retrain health personnel and to upgrade their skills. Further, innovative approaches to contraceptive distribution, such as commercial and community distribution, could help extend services at low cost. Carefully done operations research studies could be usefully conducted in these areas. The crisis facing the health delivery system poses a major constraint to the development and expansion of family planning activities, particularly as regards improving service delivery through a cafeteria approach to contraceptive distribution at the commune health center level. An acute shortage of funds exists and "the government health budget can meet no more than 40 percent of the minimum requirements which are needed to maintain the current level of services; health workers are usually only paid about 50 percent of their salaries" (UNDP, 1990). Several recent analyses of the health sector in general

or of particular components point to a system in need of major reforms (Abbatt, 1990; Allman, 1990, 1991a, and 1991b; Lam San Go et al., 1988; Pond and Johnson, 1988; Quinn-Judge, 1986; Riley, 1989; Schofield, 1989; Segall, 1988).The possibility of upgrading staff and facilities is severely limited by resource constraints that are likely to worsen as the government tries to divest itself of costly social services. Privatization and decentralization are increasingly looked to as solutions, but it is not at all clear where needed funds will come from to pay for services, supplies, and drugs. New Economic Policies Although it has taken time for Vietnam's economic renovation policies to be applied and have an impact, major improvements were evident by 1990. Agricultural production increased significantly after rules governing the cooperative system were relaxed. State enterprises were laying off workers in an effort to improve management and to function without government subsidies. Joint ventures and tourism were receiving strong governmental support, and more foreigners were visiting the country (Hiebert,1990;Vietnam Tourism, 1990;Le Phuong, 1990b). Before Vietnam's future prospects can be assessed, the application of economic policies and the performance of the economy need to be evaluated in detail. Two conferences, one in Hanoi sponsored by the American Social Science Research Council in June 1990, and the other at the Australian National University in September 1990, began the process of evaluation and concluded that there are grounds for guarded optimism concerning an economic turnaround in Vietnam. The implications for fertility are not yet clear. One can argue that economic development will lead to further modernization and the type of social change that has supported demographic transitions throughout the region. This possibility seems to be the most likely scenario. However, some local observers are afraid that relaxation of government control-especially the dismantling of cooperatives, which are fast disappearing-will mean that parents will be motivated to have more children so that they can help work the land and produce more crops. Perhaps, as occurred in China, decollectivization will undermine policy enforcement (see Greenhalgh, 1989). Rural cadres will haveless control over familieswho wish to have more than two children. Demographers and sociologists at the Institute of Sociology are currently studying this hypothesis, and their findings should be available soon. In spite of the obstacles confronting Vietnam's development efforts and population program, the country's past achievements in the face of seemingly overwhelming obstacles and the increasing pragmatism of economic Volume 22 Number 5 September/October 1991 315

policies permit the hope that family planning efforts in vietnam will improve, and fertility will continue to decline. Broadening and expanding international cooperation and assistance now could greatly help Vietnam to improve its health and population activities.

Dang Nguyen Anh. 1989. "Women, work and family ~ l a n n i nin~two rural communes in Vietnam." Women's Union Baseline Survey 1989, Preliminary Report. Hanoi: Institute of Sociology. Desbarats, Jacqueline. 1987. "Population redistribution in the Socialist Republic of Vietnam." Population and Development Review 1 3 , l : 4375. devylder, Stefan and Adam Fford. 1988. Vietnam, A n Economy in Transition. Stockholm: SIDA.

Acknowledgments

Eisen, Arlen. 1984. Women and Revolution in Viet Nam. London: Zed. Fraser, Stewart E. 1985. "Vietnam struggles with exploding population." Indochina Issues, No. 57.

Research for this report was conducted while the first author was resi, 1988. "Vietnam's population growth: Old struggle, new stratdent in Vietnam in 1989-91. Many of the data were provided by the egy." lndochina Issues, No. 58. National Committee on Population and Family Planning (NCPFP), Statistics whichreceives m a j o r s u p p o r t f r o m t ~ e ~~~ ~ ~h, ~expressed ~ ~ General i ~ i Office ~ (GSO). ~ 1990. ~ Vietnam Population Census-1989: Sample Results. Hanoi: GSO. in the paper are thoseof theauthors; they should not be taken as expressing those of the NCPFP or the UNFPA. The authors wish to acknowlGoose, Stephen D. and R. Kyle Horst. 1988. "Amerasians in Vietnam: edge the helpful suggestions of the following people on an earlier verStill waiting." Indochina Issues, No. 83.

sion of the report: Yves Charbit, Youssef Courbage, Peter Foley, Terry GovernmentofVietnam,1990. ~~~ie~nampopulationcensus

1989:Sample Hull, and Sheila Macrae. results." Hanoi: Central Census Steering Committee. Greenhalgh, Susan. 1988. "Fertility as mobility: Sinic transitions." Population and Development Review 14,4: 629-674.

References Abbatt, Fred. 1990. "An analysis of health and health manpower, Vietnam, 1989." Sweden-Vietnam Primay Health Project Report. Hanoi: Indevelop/ Swedish International Development Authority (SIDA). Allen, S.P.S. and Nguyen The Thach. 1989. "Woman's health survey, Vinh Phu and Ha Tuyen provinces." Sweden-Vietnam Primary Health Project Report. Hanoi: SIDA. Allman, James. 1990. "Primary health care needs in Phu Luong District, Bac Thai Province, Vietnam." Hanoi: International Cooperation for Development and Solidarity (CIDSE).

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Vietnamese Commune. London: Zed. Huynh Kim Khanh. 1988. "Vietnam's reforms: 'Renewal or death."' Indochina Issues, No. 84.

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Beresford, Melanie. 1988. Vietnam Politics, Economics and Society. London and New York: Pinter. Bongaarts, John. 1982. "The fertility-inhibiting effects of the intermediate fertility variables." Studies in Family Planning 1 3 , 6 / 7 : 179-189. Caldwell, John C. 1986. "Routes to low mortality in poor countries." Population and Development Review 12,2: 171-220.

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Morley, David,JonRohde,andGlen Williams, eds. 1983.PractisingHealth for All. London: Oxford University Press. National Committee for Population and Family Planning (NCPF'P). 1990. "Population and family planningactivities, 1979-89 and population and family planning plan, 1990 and 1991-95 for Vietnam." Hanoi: NCPF'P. . 1990a. Vietnam Demographic and Health Survey, 1988. Hanoi: NCPFP.

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N ~ u Y Thu ~ " NgaandPol1y Weissner. 1986. "Breast-feedingandyoung child nutrition in Uong Bi, Quang Ninh Province, Vietnam." Journal of Tropical Pediatrics 32: 137-139.

316 Studies in Family Planning

Nguyen Xuan Oanh. 1988. "Some observations and remarks." Paper presented at the Harvard Institute for International Development, Cambridge, MA. Pond, Robert S. and Bekki J. Johnson. 1988. "Health in Vietnam: A Report to CIDSE." Hanoi: CIDSE. Quinn-Judge, Sophie. 1986."Shortages confront Vietnam's health care." Indochina Issues, No. 65. Riley, I.D. 1989. "Assignment report, public health training and development, Socialist Republic of Vietnam, 3-15 May 1989." Hanoi: UNICEF. Ruscio, Alain, ed. 1989. Viet Narn, l'histoire, la terre, les hommes. Paris: L'Harmattan. Schofield, Frank C. 1989. "Report on an EPI field visit to Sr. Viet Nam." Hanoi: UNICEF. Segall, Malcolm. 1988. "Primary health in Quang Ninh, Vinh Phu and Ha Tuyenprovinces: Areview of theVietnam-Sweden primary health care project." Hanoi: SIDA. Socialist Republic of Vietnam, Ministry of Health. 1989. "Programme of actions of the health service in the 1989-1990 period." Hanoi: Ministry of Health. Socialist Republic of Vietnam, National Committee for Population and Family Planning. 1990. Vietnam Demographicand Health Survey, 1988. Hanoi: NCPFP. Tam Quach-Langlet. 1989."La femme." In Viet Nam, l'histoire, la terre, les hommes. Ed. Alain Ruscio. Paris: L'Harmattan. The Duy. 1990. "Food production in Vietnam." Vietnam Courier, No. 5, p. 11.

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Thrift, Nigel J. 1987. " 'Difficult years': Ideology and urbanization in South Vietnam, 1975-1986." Urban Geography 8,5: 420-439.

Volume 22 Number 5 September/October 1991 317

Fertility and Family Planning in Vietnam James Allman

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