Abstract
Background
Vietnam has made substantial progress in maternal health, achieving high coverage of antenatal care (ANC) under the Millennium Development Goals. However, focusing solely on the number of ANC contacts may obscure whether women receive the essential services recommended during pregnancy. This study examined trends in ANC contacts and service content across sociodemographic groups and assessed whether inequalities changed over time.
Methods
We analyzed nationally representative Multiple Indicator Cluster Survey (MICS) data from 2011, 2014, and 2021 for women aged 15-49 years who had a live birth in the two years preceding the survey (N = 4,413). Outcomes included ANC coverage (≥4 and ≥8 contacts), ANC provided by skilled health personnel, ANC provided by medical doctors, receipt of four core ANC services (tetanus immunization, blood pressure measurement, blood test, and urine test), and a Complete ANC Coverage Index reflecting both service contacts and essential ANC content. Survey-weighted logistic regression models examined temporal trends and differences by wealth, residence, region, and ethnicity.
Results
From 2011 to 2021, all ANC indicators improved significantly (all p < 0.001). Coverage of ANC provided by skilled health personnel increased from 93.3% to 97.0%, while ANC provided by medical doctors increased from 80.6% to 95.0%. The proportion of women receiving all four core ANC services increased from 39.9% to 63.2%, and the Complete ANC Coverage Index more than doubled from 15.2% to 39.2%. Improvements were observed across all sociodemographic groups; however, substantial inequalities persisted. For the Complete ANC Coverage Index, temporal trends differed significantly across regions and places of residence (p < 0.05). Still, they were similar across wealth quintiles and ethnic groups (p > 0.05), despite persistent differences in absolute coverage.
Conclusion
Vietnam has achieved substantial improvements in both ANC contacts and service content, yet important inequalities remain. Monitoring both service contacts and essential ANC content, using complementary measures such as the Complete ANC Coverage Index, provides a more comprehensive assessment of effective ANC coverage and may better inform policies to promote equitable maternal healthcare.
Keywords: antenatal care, maternal health, effective coverage, health inequalities, Vietnam, multiple indicator cluster survey (MICS), sustainable development goals
Introduction
Over the past two decades, Vietnam has made notable progress in improving maternal and child health, reflecting its commitment to the Millennium Development Goals (MDGs) 1 and its continued efforts under the Sustainable Development Goals (SDGs). The proportion of women receiving antenatal care (ANC) and delivering in health facilities has steadily increased, contributing to substantial reductions in maternal mortality and adverse birth outcomes. 2 According to United Nations inter-agency estimates, the maternal mortality ratio in Vietnam declined from 88 deaths per 100,000 live births in 2000 to 46 per 100,000 in 2020, although it remains considerably higher in mountainous and ethnic minority regions. 3 Ensuring universal access to high-quality ANC remains a key strategy for reducing preventable maternal and neonatal deaths and achieving SDG target 3.1 on maternal mortality. By 2021, more than 97% of pregnant women had at least one ANC contact with skilled health personnel, and approximately 88% had received at least four contacts. 4 These figures demonstrate the expanding reach of Vietnam’s primary healthcare system and targeted initiatives, such as the National Strategy on Reproductive Health.
While previous international studies have highlighted that simply tracking the number of antenatal care (ANC) contacts may not be sufficient to ensure safe pregnancy outcomes,5-7 Vietnam’s experience across multiple rounds of the Multiple Indicator Cluster Surveys (MICS) provides a valuable example for other low- and middle-income countries (LMICs) on how trends in both contact and content can be monitored over time. It is equally important to examine whether ANC contacts include key recommended services that help prevent pregnancy-related complications.6,7 Essential services, such as tetanus toxoid vaccination, blood pressure measurement, and routine blood and urine tests, are well-established interventions for reducing maternal and neonatal risks.2,8 However, despite nearly 88% of women receiving at least four ANC contacts, only about 74% received all three basic clinical tests 4 in Vietnam in 2021, highlighting a persistent gap between visit coverage and the actual content of care. This distinction between service contact and the delivery of recommended interventions has increasingly been recognized as a key dimension of effective coverage, emphasizing that contact with health services alone does not necessarily translate into high-quality care or improved health outcomes. 9
Previous studies using MICS data in Vietnam have primarily focused on visit counts and, more recently, on whether women received selected clinical services during their ANC contacts. 10 However, in the current MICS format, ANC contacts, the three core clinical checks (blood pressure measurement and urine and blood tests), and tetanus vaccination are reported as separate indicators. 4 This separation makes it difficult to assess whether women receive a full package of essential services during pregnancy. To address this gap, previous studies have proposed using composite indicators that combine both visit coverage and the content of care to better reflect effective coverage and quality over time.5,6,11 Combining these elements into a single, easy-to-interpret indicator can help countries like Vietnam and other LMICs track changes over time more effectively and provide policymakers with a clearer benchmark for monitoring progress toward the SDGs’ targets for high-quality, equitable maternal health services. In addition to the standard WHO indicator of ANC provided by skilled health personnel, examining ANC provided by medical doctors may offer complementary information on women’s access to physician-led antenatal services within the Vietnamese health system, where physicians are typically concentrated in higher-level facilities.
Importantly, while national-level figures suggest that Vietnam has largely met key maternal health targets under the MDGs, there remains a clear need to understand gaps in both coverage and content of ANC services among different population groups.5-7,12 Women living in remote or rural areas, ethnic minority communities, or lower socioeconomic households may still face multiple barriers, such as long travel distances, language challenges, or limited access to qualified providers, which compromise timely and comprehensive care.12-14 Although national reports provide valuable aggregate data, further analysis is needed to pinpoint where shortfalls in access and service quality persist.7,12 Such evidence is essential for designing targeted, equity-focused interventions that respond effectively to the needs of these vulnerable groups and align with Vietnam’s SDG commitments. To address this gap, this study uses MICS data from 2011, 2014, and 2021 to examine trends in ANC contact and content, including whether women receive essential services such as tetanus vaccination, blood pressure checks, and blood and urine tests. It also evaluates coverage of ANC provided by skilled health personnel and by medical doctors as complementary measures of access to antenatal care. More importantly, it examines how these measures vary across sociodemographic factors such as wealth, ethnicity, region, and urban–rural residence over time, providing updated evidence to support equitable progress toward Vietnam’s SDG targets for maternal health.
Methodology
Data Sources and Study Samples
This study used data from Vietnam MICS conducted in 2011 (N=11,633), 2014 (N=9,827), and 2021 (N=11,283). The MICS is a nationally representative household survey program developed by UNICEF to provide internationally comparable data on children and women. 4 Each survey employed a cross-sectional design using standardized questionnaires, field procedures, and multistage stratified cluster sampling methods developed by UNICEF to ensure comparability across survey rounds. Women aged 15-49 years who had a live birth during the two years preceding each survey were eligible for inclusion. Women outside this age range or without a live birth during the reference period were excluded from the analysis, consistent with the MICS maternal health module. The final analytic sample included 1,363 women in 2011, 1,484 women in 2014, and 1,566 women in 2021.
Although the Vietnam MICS was also conducted in 2006, this survey was not included because it did not collect information on the number of ANC contacts, thereby precluding calculation of the WHO-recommended ANC contact indicators (≥4 and ≥8 contacts) and the Complete ANC Coverage Index. The study therefore focused on the 2011, 2014, and 2021 survey rounds, which provided comparable information on both ANC contacts and service content.
Study Measurements
This study examined six maternal healthcare indicators. Four indicators followed the standard MICS framework 10 to ensure comparability over time and across surveys. These include the proportion of women aged 15-49 years with a live birth in the past two years who received at least one ANC visit provided by skilled health personnel (the standard MICS/WHO indicator), ANC provided by a medical doctor, at least four ANC contacts (reflecting the WHO focused ANC model), and at least eight ANC contacts (aligned with the updated WHO recommendation for a positive pregnancy experience). For consistency across survey rounds, ANC ≥4 contacts was retained because it was available in all three survey years, whereas ANC ≥8 contacts was included to assess progress towards the updated 2016 WHO recommendation, where data permitted. 15 ANC provided by a medical doctor was examined as a complementary indicator of women’s access to physician-led antenatal care and was not intended to replace the standard WHO/MICS indicator based on skilled health personnel.
In addition to these standard indicators, this study developed two composite measures to capture better ANC adequacy: the percentage of women who received all core ANC services and the Complete ANC Coverage Index.
The first composite measure combined complete tetanus toxoid immunization with the three core clinical services (blood pressure measurement, urine test, and blood test). Following the MICS definition, complete tetanus toxoid immunization was defined as receiving at least two doses during the most recent pregnancy or being considered protected based on previous vaccination history (i.e., at least two doses within the previous three years, at least three doses within five years, at least four doses within ten years, or five or more lifetime doses),10,16 In the MICS report, tetanus immunization is reported separately and is not included in the standard ANC content indicator.
The second composite indicator, the Complete ANC Coverage Index, combined receipt of all four core services with at least eight ANC contacts, consistent with the WHO recommendation for a positive pregnancy experience, 15 to capture whether women received both sufficient contact and comprehensive core care during pregnancy.
Key sociodemographic characteristics were included as independent variables in this analysis. Age was grouped into standard five-year intervals (15-19, 20-24, 25-29, 30-34, 35-39, 40-44, and 45-49 years), consistent with official MICS reports. 10 Ethnicity of the household head was classified as Kinh and Hoa or other ethnic minority groups to ensure stable estimates during the analyses. Socioeconomic status (SES) was measured using the household wealth index, constructed via principal component analysis of household assets and living conditions. This approach is widely used and standardized in MICS and other large household surveys in LMICs to assess relative economic status, 10 and its validity has also been reported in Vietnam. 17 The wealth index was divided into quintiles, from the poorest (lowest) to the richest (highest). Region of residence was grouped according to Vietnam’s six national geographical regions, as defined in the MICS sampling design: Red River Delta, Northern Midlands and Mountains, North Central and Central Coastal Areas, Central Highlands, Southeast, and Mekong River Delta. Place of residence was categorized as urban or rural, following the national sampling frame and administrative classifications used by the General Statistics Office of Vietnam. 10
Statistical Analysis
Prevalence estimates (overall and by subgroup) and their 95% confidence intervals for antenatal care (ANC) indicators in 2011, 2014, and 2021 were calculated. Time trends for key ANC outcomes were then examined across subgroups defined by demographic factors (e.g., area of residence, region, and ethnicity) and SES (i.e., wealth quintiles). Multiple logistic regression models were used to examine significant time trends and group differences at each time point, adjusting for potential variations in sample characteristics (age, ethnicity, region, and SES). Interaction terms between survey year and each sociodemographic variable tested whether trends differed significantly across demographic and SES factors. All analyses applied appropriate sampling weights to account for the complex survey design in Stata 18 using the svy procedures. A p-value of <0.05 was considered statistically significant.
Ethics Approval
The original MICS surveys were conducted in accordance with UNICEF’s standard ethical procedures, and all datasets were fully de-identified before public release. Therefore, no additional ethical approval was required for this secondary analysis.
Results
Study Sample Characteristics
Table 1 presents the sociodemographic characteristics of women aged 15-49 years who had a live birth in the 2 years preceding each survey. The age distribution of the mothers changed over the three survey years. The proportion of mothers aged 15-19 years increased from 5.5% in 2011 to 8.2% in 2021, while that of women aged 35-49 years rose from 11.4% to 16.1% over the same period. In contrast, the proportion of women aged 20-29 years has declined. The distribution by ethnicity showed a decrease in the proportion of Kinh and Hoa mothers (from 78.9% to 54.9%). The proportion of mothers with an upper secondary or higher education increased from 42.3% in 2011 to 49.2% in 2021. Regarding residence, the proportion of urban mothers decreased from 39.8% to 25.8%. The distribution of mothers by region also changed over time, with an increase in the proportion of women from the Northern Midlands and Mountains (from 20.4% to 27.7%), and a decrease in those from the Central Highlands (from 20.0% to 13.7%). These differences between years were statistically significant across the survey years (p < 0.05).
Table 1.
Characteristics of Women Aged 15-49 Who had a Live Birth in the Two Years Preceding the Survey in Vietnam, Based on Data From MICS 2011, 2014, and 2021
| Characteristic | Year 2011 (N=1363) n (%) | Year 2014 (N=1484) n (%) | Year 2021 (N=1566) n (%) |
|---|---|---|---|
| Age group | |||
| 15-19 | 75 (5.5) | 95 (6.4) | 128 (8.2) |
| 20-24 | 378 (27.7) | 379 (25.5) | 350 (22.3) |
| 25-29 | 472 (34.6) | 470 (31.7) | 467 (29.8) |
| 30-34 | 283 (20.8) | 369 (24.9) | 369 (23.6) |
| 35-49 | 155 (11.4) | 171 (11.5) | 252 (16.1) |
| Ethnicity of household head | |||
| Kinh and Hoa | 1076 (78.9) | 1132 (76.3) | 859 (54.9) |
| Other minorities | 287 (21.1) | 352 (23.7) | 707 (45.1) |
| Marital status | |||
| Currently married/in union | 1342 (98.5) | 1444 (97.3) | 1521 (97.1) |
| Not married/in union | 14 (1.0) | 38 (2.6) | 39 (2.5) |
| No information | 7 (0.5) | 2 (0.1) | 6 (0.4) |
| Education level | |||
| Pre-primary or none | 90 (6.6) | 89 (6.0) | 178 (11.4) |
| Primary | 204 (15.0) | 199 (13.4) | 177 (11.3) |
| Lower secondary | 492 (36.1) | 513 (34.6) | 441 (28.2) |
| Upper secondary or higher | 577 (42.3) | 595 (40.1) | 770 (49.2) |
| Area | |||
| Urban | 542 (39.8) | 558 (37.6) | 404 (25.8) |
| Rural | 821 (60.2) | 926 (62.4) | 1162 (74.2) |
| Region | |||
| Red River Delta | 203 (14.9) | 227 (15.3) | 259 (16.5) |
| Northern Midlands & Mountains | 278 (20.4) | 280 (18.9) | 434 (27.7) |
| North Central & Central Coast | 207 (15.2) | 222 (15.0) | 216 (13.8) |
| Central Highlands | 272 (20.0) | 308 (20.8) | 214 (13.7) |
| Southeast | 215 (15.8) | 244 (16.4) | 237 (15.1) |
| Mekong River Delta | 188 (13.8) | 203 (13.7) | 206 (13.2) |
Trends in antenatal care coverage and content
Table 2 shows a significant improvement in all antenatal care (ANC) indicators among women aged 15-49 years in Vietnam between 2011 and 2021. The proportion of women attending at least four ANC contacts, a traditional measure of ANC coverage, increased substantially over time, reaching more than 90% in 2021. Coverage of ANC provided by skilled health personnel was consistently high throughout the study period, increasing from 93.3% (91.1-95.4%) in 2011 to 97.0% (96.0-98.1%) in 2021. Coverage of ANC provided by medical doctors also increased markedly, from 80.6% (77.3-84.0%) to 95.0% (93.6-96.4%). More importantly, the quality and completeness of care improved. The proportion of women receiving adequate ANC content increased from 39.9% (36.2-43.5%) in 2011 to 63.2% (59.7-66.8%) in 2021, while the proportion achieving the Complete ANC Coverage Index, reflecting both adequate contact (≥8 ANC contacts) and receipt of all core ANC services, more than doubled from 15.2% (12.5-17.9%) to 39.2% (35.6-42.7%). Between 2011 and 2021, all ANC indicators showed significant improvements over time (p for trend <0.001).
Table 2.
Trends in Antenatal Care Indicators Among Women Aged 15-49 Who had a Live Birth in the Two Years Preceding the Survey in Vietnam, Based on Data From MICS 2011, 2014, and 2021
| Indicator | Year 2011 % (95% CI) | Year 2014 % (95% CI) | Year 2021 % (95% CI) | p-value for trend* |
|---|---|---|---|---|
| % of ANC ≥4 contacts | 65.2 (61.4, 68.9) | 78.1 (75.4, 80.8) | 92.3 (90.3, 94.2) | <0.001 |
| % of ANC ≥8 contacts | 27.8 (24.5, 31.0) | 33.7 (30.4, 37.0) | 56.8 (53.1, 60.5) | <0.001 |
| % of ANC by skilled health personnel | 93.3 (91.1, 95.4) | 95.8 (93.9, 97.6) | 97.0 (96.0, 98.1) | <0.001 |
| % of ANC by medical doctor | 80.6 (77.3, 84.0) | 88.8 (86.4, 91.2) | 95.0 (93.6, 96.4) | <0.001 |
| % of adequate ANC content | 39.9 (36.2, 43.5) | 49.3 (45.9, 52.6) | 63.2 (59.7, 66.8) | <0.001 |
| % of complete ANC index | 15.2 (12.5, 17.9) | 21.4 (18.7, 24.1) | 39.2 (35.6, 42.7) | <0.001 |
*p-value from multiple logistic regression models adjusting for variation in sample characteristics over time.
Inequalities by region, rural/urban, and ethnicity
Most ANC indicators improved significantly for both minority ethnic groups and Kinh/Hoa women over the study period (Table 3). Minority women made larger gains in receiving care from a doctor and in achieving at least 4 ANC contacts, helping to narrow some gaps, but they were still behind overall. By 2021, about two-thirds of minority women had at least four contacts, compared with near-universal coverage among Kinh/Hoa women. Coverage of ANC provided by skilled health personnel remained consistently high in both ethnic groups but was persistently lower among minority women (72.5% to 85.5%) than among Kinh/Hoa women (97.3% to 99.4%). Access to a doctor among minority women rose from about 45% to about 79%, while it remained consistently high among Kinh/Hoa women at about 98%. However, notable gaps persisted for eight or more ANC contacts (i.e., only about 33% of minority women reached this level compared with around 62% of Kinh/Hoa women) and for receiving full content of ANC services (i.e., minority women at about 43% versus roughly 68% for Kinh/Hoa women).
Table 3.
Inequalities in ANC Coverage and Quality Among Women Aged 15–49 Who had a Live Birth in the Two Years Preceding the Survey in Vietnam by Area of Residence, and Ethnicity, Based on MICS Data From 2011, 2014, and 2021
| Indicator | Year 2011 | Year 2014 | Year 2021 | p for group difference* | p for trend difference |
|---|---|---|---|---|---|
| % (95% CI) | (95% CI) | (95% CI) | |||
| Trend by Ethnicity | |||||
| ANC ≥ 4 contacts | |||||
| Minority | 46.1 (36.8, 55.5) | 53.3 (46.1, 60.5) | 66.7 (59.3, 74.1) | <0.05 | <0.05 |
| Kinh and Hoa | 68.9 (65.0, 72.7) | 83.2 (80.6, 85.8) | 97.7 (96.6, 98.9) | ||
| ANC ≥ 8 contacts | |||||
| Minority | 28.8 (19.8, 37.9) | 28.1 (19.2, 36.9) | 32.9 (25.9, 39.8) | <0.05 | <0.05 |
| Kinh and Hoa | 27.6 (24.2, 30.9) | 34.9 (31.4, 38.4) | 61.9 (57.8, 66.0) | ||
| Adequate ANC Content | |||||
| Minority | 12.8 (7.7, 17.9) | 21.0 (14.1, 27.9) | 42.9 (36.1, 49.8) | <0.05 | <0.05 |
| Kinh and Hoa | 45.1 (41.1, 49.1) | 55.1 (51.6, 58.6) | 67.5 (63.6, 71.5) | ||
| ANC by skilled health personnel | |||||
| Minority | 72.5 (62.7, 82.3) | 79.0 (69.9, 88.2) | 85.5 (80.6, 90.4) | | |
| Kinh and Hoa | 97.3 (96.1, 98.5) | 99.2 (98.7, 99.8) | 99.4 (98.9, 99.9) | | |
| ANC by the doctor | |||||
| Minority | 44.5 (35.9, 53.1) | 67.5 (58.3, 76.7) | 78.6 (73.0, 84.2) | <0.05 | <0.05 |
| Kinh and Hoa | 87.6 (84.8, 90.5) | 93.2 (91.4, 94.9) | 98.5 (97.5, 99.4) | ||
| Complete ANC Index | |||||
| Minority | 0.6 (0.0, 1.6) | 5.8 (2.6, 9.0) | 15.0 (10.1, 19.9) | <0.05 | >0.05 |
| Kinh and Hoa | 18.0 (14.9, 21.1) | 24.6 (21.5, 27.7) | 44.3 (40.3, 48.4) | ||
| Trend by area of residence | |||||
| ANC ≥ 4 contacts | |||||
| Urban | 84.0 (80.0, 88.1) | 86.9 (83.3, 90.5) | 97.5 (95.8, 99.3) | <0.05 | <0.05 |
| Rural | 57.4 (52.8, 62.1) | 74.5 (71.0, 77.9) | 89.9 (87.2, 92.6) | ||
| ANC ≥ 8 contacts | |||||
| Urban | 44.2 (38.7, 49.8) | 48.6 (43.7, 53.5) | 74.8 (69.1, 80.5) | <0.05 | <0.05 |
| Rural | 21.0 (17.3, 24.7) | 27.6 (23.5, 31.7) | 48.7 (44.0, 53.3) | ||
| Adequate ANC Content | |||||
| Urban | 60.8 (55.0, 66.6) | 60.1 (55.5, 64.7) | 74.0 (69.0, 79.1) | <0.05 | <0.05 |
| Rural | 31.3 (27.1, 35.4) | 44.8 (40.6, 49.1) | 58.3 (53.8, 62.7) | ||
| ANC by skilled health personnel | |||||
| Urban | 97.9 (96.5, 99.4) | 99.1 (98.2, 100.0) | 99.4 (98.7, 100.0) | <0.05 | <0.05 |
| Rural | 91.3 (88.3, 94.4) | 94.4 (91.8, 97.0) | 95.9 (94.4, 97.4) | | |
| ANC by the doctor | |||||
| Urban | 94.7 (92.5, 96.8) | 96.4 (94.5, 98.3) | 99.3 (98.5, 100.0) | <0.05 | >0.05 |
| Rural | 74.9 (70.4, 79.4) | 85.6 (82.4, 88.9) | 93.0 (91.0, 95.0) | ||
| Complete ANC Index | |||||
| Urban | 33.6 (28.0, 39.2) | 34.8 (30.1, 39.5) | 55.5 (49.9, 60.9) | <0.05 | <0.05 |
| Rural | 7.6 (5.1, 10.1) | 15.9 (12.8, 18.9) | 31.8 (27.4, 36.1) | ||
Significant differences were found between rural and urban areas for all six indicators, with temporal trends differing significantly for all indicators except ANC provided by a medical doctor (logistic regression, p-value for trend < 0.05). Gaps narrowed for ANC ≥ 4 contacts and % of ANC by doctor: rural coverage rose sharply while urban coverage remained high, pushing both to near-universal levels. Coverage of ANC provided by skilled health personnel exceeded 95% in rural areas and 99% in urban areas by 2021, although significant urban–rural differences persisted. Inequities remain for ANC, with at least eight contacts, and for the share of women who receive the full content of ANC services. In 2021, about 75% of urban women had eight or more contacts compared with 49% of rural women, and coverage of receiving full content of ANC services was around 74% in urban areas versus about 58% in rural areas.
Coverage levels and temporal trends for all ANC indicators varied significantly across the six regions of Vietnam (all p < 0.05), with persistent disparities particularly in the Northern Midlands and Mountains and the Central Highlands. In contrast, the Red River Delta and Southeast consistently achieved the highest coverage across most indicators (Supplemental Table S1).
Inequalities by socio-economic status
All six ANC indicators improved across all five household wealth quintiles between 2011 and 2021 (Table 4). Nevertheless, substantial socioeconomic inequalities persisted. Coverage of ANC with at least four contacts, ANC with at least eight contacts, ANC provided by skilled health personnel, and ANC provided by medical doctors increased significantly across all wealth groups, with significant differences between quintiles throughout the study period (all p for group < 0.01). The interaction between survey year and wealth quintile was significant for ANC with at least four contacts, ANC with at least eight contacts, and ANC provided by medical doctors (all p for trend difference <0.05), indicating differing temporal trajectories across wealth groups. In contrast, trends in ANC, as provided by skilled health personnel, adequate ANC content, and the Complete ANC Coverage Index, were broadly comparable across wealth quintiles (all p-values for trend >0.05). Despite overall improvements, women in the poorest quintile consistently had the lowest coverage across all indicators, particularly for ANC with at least eight contacts, adequate ANC content, and the complete ANC coverage index.
Table 4.
Socioeconomic Inequalities in ANC Coverage and Quality Among Women Aged 15-49 Who had a Live Birth in the Two Years Preceding the Survey in Vietnam, Based on MICS Data From 2011, 2014, and 2021
| Wealth quintile | Year 2011 % (95% CI) | Year 2014 % (95% CI) | Year 2021 % (95% CI) | p for group difference* | p for trend difference |
|---|---|---|---|---|---|
| ANC ≥4 contacts | p<0.01 | p<0.05 | |||
| Poorest | 47.2 (39.9, 54.5) | 56.5 (49.9, 63.1) | 72.2 (65.1, 79.2) | | |
| Poor | 47.9 (38.8, 57.1) | 69.1 (63.0, 75.2) | 91.9 (87.7, 96.1) | | |
| Middle | 60.1 (52.0, 68.1) | 78.2 (72.5, 83.9) | 99.7 (99.2, 100.0) | | |
| Rich | 79.5 (73.0, 85.9) | 90.0 (86.4, 93.6) | 99.1 (97.7, 100.0) | | |
| Richest | 89.9 (85.1, 94.7) | 96.9 (94.6, 99.2) | 100.0 | | |
| ANC ≥8 contacts | p<0.01 | p<0.05 | |||
| Poorest | 23.4 (16.4, 30.3) | 23.6 (15.6, 31.6) | 27.4 (20.9, 34.0) | | |
| Poor | 14.6 (9.2, 20.1) | 15.8 (10.9, 20.6) | 49.2 (41.5, 56.9) | | |
| Middle | 15.4 (9.9, 20.9) | 26.9 (20.7, 33.0) | 62.1 (54.5, 69.7) | | |
| Rich | 29.7 (23.2, 36.2) | 45.1 (38.5, 51.8) | 73.3 (66.3, 80.4) | | |
| Richest | 52.5 (44.8, 60.2) | 57.6 (50.9, 64.3) | 74.5 (66.7, 82.4) | | |
| ANC by skilled health personnel | p<0.01 | p>0.05 | |||
| Poorest | 76.7 (69.2, 84.2) | 81.3 (73.5, 89.2) | 87.7 (83.3, 92.0) | | |
| Poor | 95.7 (92.5, 98.9) | 98.3 (96.5, 100.0) | 99.1 (97.8, 100.0) | | |
| Middle | 97.2 (94.5, 100.0) | 99.7 (99.1, 100.0) | 99.6 (98.8, 100.0) | | |
| Rich | 99.2 (98.3, 100.0) | 100.0 | 99.4 (98.5, 100.0) | | |
| Richest | 99.1 (97.5, 100.0) | 99.7 (99.1, 100.0) | 99.6 (98.9, 100.0) | | |
| ANC by a medical doctor | p<0.01 | p<0.05 | |||
| Poorest | 51.1 (42.8, 59.5) | 69.5 (61.7, 77.2) | 82.2 (77.1, 87.2) | | |
| Poor | 77.1 (69.8, 84.4) | 88.5 (84.3, 92.8) | 98.1 (95.6, 100.0) | | |
| Middle | 86.3 (80.8, 91.8) | 92.3 (88.5, 96.1) | 99.2 (98.2, 100.0) | | |
| Rich | 92.1 (88.1, 96.1) | 95.9 (93.5, 98.2) | 97.8 (95.8, 99.7) | | |
| Richest | 98.2 (96.5, 100.0) | 97.9 (96.2, 99.7) | 98.3 (95.8, 100.0) | | |
| Adequate ANC content | p<0.01 | p>0.05 | |||
| Poorest | 16.2 (10.6, 21.8) | 21.6 (15.6, 27.6) | 40.4 (33.6, 47.3) | | |
| Poor | 27.1 (19.6, 34.6) | 43.9 (37.2, 50.7) | 64.3 (56.7, 72.0) | | |
| Middle | 35.3 (27.6, 42.9) | 50.5 (43.9, 57.1) | 68.0 (60.9, 75.2) | | |
| Rich | 51.3 (43.5, 59.1) | 59.9 (53.5, 66.3) | 71.8 (64.9, 78.6) | | |
| Richest | 68.5 (61.6, 75.4) | 70.9 (65.1, 76.7) | 72.8 (64.8, 80.8) | | |
| Complete ANC Coverage Index | p<0.01 | p>0.05 | |||
| Poorest | 0.9 (0.0, 2.1) | 3.2 (0.9, 5.5) | 11.5 (6.4, 16.6) | | |
| Poor | 6.2 (2.3, 10.1) | 9.0 (5.3, 12.7) | 32.7 (25.1, 40.3) | | |
| Middle | 7.3 (3.2, 11.4) | 19.2 (13.8, 24.5) | 45.3 (37.8, 52.8) | | |
| Rich | 18.5 (12.7, 24.4) | 32.0 (26.0, 38.1) | 51.6 (43.3, 59.8) | | |
| Richest | 41.2 (33.4, 49.0) | 43.9 (37.9, 50.1) | 57.3 (49.3, 65.3) | | |
*From multiple logistic regression models (p-values for interaction terms indicate whether trends differed significantly across subgroups; main effects assess differences between groups at each time point).
Complete ANC coverage over time
Figure 1 illustrates improvements in the Complete ANC Coverage Index across all sociodemographic groups between 2011 and 2021. Survey-weighted logistic regression models showed significant overall differences in coverage by socioeconomic status (SES), ethnicity, area of residence, and region (main effects: all p < 0.05). However, significant interactions with survey year were observed only for region and area of residence (interaction terms: p < 0.05), indicating that temporal trends differed across these subgroups. In contrast, interactions between survey year and SES or ethnicity were not statistically significant (p > 0.05), suggesting broadly similar rates of improvement over time despite persistent differences in absolute coverage.
Figure 1.
Trends in the complete ANC Coverage Index among women aged 15-49 with a live birth in the past two years, Vietnam MICS 2011, 2014, and 2021
Coverage increased across all SES groups, from 0.9% to 11.5% among the poorest quintile and from 41.2% to 57.3% among the richest quintiles. Similarly, coverage increased from 0.6% to 15.0% among ethnic minority women and from 18.0% to 44.3% among Kinh/Hoa women. Urban coverage increased from 33.6% to 55.5%, while rural coverage increased from 7.6% to 31.8%. Regional improvements were observed across all six regions. However, the magnitude of improvement varied, with the Southeast maintaining the highest coverage (39.6% to 58.9%) and the Northern Midlands and Mountains remaining the lowest (5.4% to 18.4%).
Discussion
This study shows that over the past decade, Vietnam has made substantial progress in antenatal care (ANC), with improvements in both service contact and quality of care. From 2011 to 2021, the proportion of women attending at least four ANC contacts rose from 65% to over 92%, surpassing the average in many lower-middle-income countries, where coverage for four or more contacts often remains at around 80%. 18 Coverage for eight or more visits more than doubled during the same period, reaching 57%, which is notably higher than the global average of about 50%. 3 Coverage of ANC provided by skilled health personnel exceeded 97% by 2021, while ANC provided by medical doctors reached 95%, indicating that although access to skilled ANC was nearly universal, access to physician-led antenatal services also expanded substantially over the past decade. Coverage of core ANC services (i.e., tetanus vaccine, blood test, urine test, and blood pressure) increased from 40% to 63%, aligning closely with global levels. 3 Together, these figures reflect strong national progress in expanding ANC access and meeting global standards. However, they also highlight the need to look beyond contact alone to assess whether women receive the full range of essential services. 5 This finding is consistent with the concept of effective coverage, which emphasizes that contact with health services alone does not necessarily ensure delivery of recommended interventions or high-quality care. Although the proportion of women achieving the complete ANC index, defined as receiving eight or more contacts and all four core services, increased significantly from 15% in 2011 to 39% in 2021, this indicator reveals a more realistic picture. Many women who appear to be covered by traditional contact-based measures still do not receive the full package of essential care. This gap between contact and content is not unique to Vietnam; similar patterns have been observed across low- and middle-income countries, where the proportion of women receiving all recommended ANC services often lags well behind visit coverage.5,11,12
This study proposes a pragmatic composite indicator to measure antenatal care (ANC) by combining the recommended number of contacts with whether women received key services. This combined indicator captures both contact (number of contacts) and content (services provided), addressing a well-known gap in maternal health monitoring: visit counts alone do not guarantee that women receive the quality care needed for better outcomes.6,12,19 A key strength of the complete ANC index is that it integrates both contact and content into a single interpretable metric, thereby offering a more meaningful measure of effective coverage. Unlike conventional indicators that assess the number of visits and receipt of services separately, this composite index reflects whether women received care that meets both the recommended content and frequency standards. It was constructed using data routinely collected from most DHS and MICS surveys, making it easily applicable across countries and over time. This simplicity and comparability make it a valuable tool for monitoring quality-adjusted ANC coverage globally. Past studies have shown that high contact alone does not guarantee quality, which supports the need for integrated indicators like the one used here. 7
Importantly, this more complete measure also uncovers hidden inequalities that are missed when we consider only visit numbers. By 2021, coverage of at least four ANC contacts had increased substantially across all sociodemographic groups, although important gaps remained among women in the poorest quintile and ethnic minority women. However, when examining the Complete ANC Coverage Index, much wider gaps were evident: coverage was 57% among women in the richest quintile compared with 11% among those in the poorest quintile, 55% among urban women compared with 32% among rural women, and the gap between Kinh/Hoa and ethnic minority women widened from 17 percentage points in 2011 to over 29 percentage points in 2021. Although this absolute gap widened, the interaction between survey year and ethnicity was not statistically significant, indicating broadly similar relative rates of improvement despite persistently lower coverage among ethnic minority women. Other studies have also found similar barriers, such as cost, language, or provider skill, that prevent disadvantaged women from receiving full care even when they reach a clinic.5-7,19,20 These findings are especially relevant for Vietnam’s progress toward the Sustainable Development Goals (SDGs). The National Strategy on Reproductive Health recognizes the need to improve both coverage and quality. Monitoring must go beyond counting visits to capture what happens during them. Routine monitoring systems should complement conventional contact-based indicators with composite measures that capture both ANC contacts and the delivery of essential services, thereby providing a more meaningful assessment of effective ANC coverage. Strengthening lower-level facilities, training providers to deliver the full ANC package, and expanding outreach, especially for minority and rural women, will be the key to ensuring that no group is left behind. 15 Improving the capacity of commune health stations and district hospitals to deliver the complete package of recommended ANC services may further reduce persistent inequalities in underserved populations.
This study had some limitations. First, all ANC data were self-reported, which may have been affected by recall bias. Second, the selected core services represent only a part of the full ANC package recommended by WHO. Third, because this is a cross-sectional analysis, it cannot show causal relationships or follow women over time. Fourth, ethnicity in the MICS refers to the household head rather than the individual woman, which may have resulted in some misclassification. However, this definition was applied consistently across all survey rounds. Finally, ANC provided by a medical doctor was analyzed as a complementary indicator that reflects access to physician-led antenatal services within the Vietnamese health system and should not be interpreted as a replacement for the WHO standard indicator of ANC provided by skilled health personnel. Despite these limitations, the strengths of this study include the use of large, nationally representative data over more than a decade and the introduction of a feasible composite indicator that captures both coverage and content. This more comprehensive measure can help Vietnam and other countries to assess better whether high ANC contact truly translates into high-quality care.
Conclusion
While Vietnam has made substantial gains in antenatal care (ANC), important gaps remain when both service contacts and essential ANC content are considered together. Only four in ten women met the Complete ANC Coverage Index in 2021, defined as receiving at least eight ANC contacts and all four assessed core services, with persistent inequalities by wealth, ethnicity, region, and place of residence. Achieving the Sustainable Development Goals will require monitoring systems that go beyond counting ANC contacts to assess the quality and completeness of care delivered. The Complete ANC Coverage Index complements conventional ANC indicators by capturing both recommended contacts and essential interventions, providing a more comprehensive measure of effective ANC coverage. Its routine use could help identify underserved populations, monitor progress more accurately, and inform policies to improve equitable, high-quality maternal healthcare.
Supplemental Material
Supplemental Material for Redefining Antenatal Care Coverage: Tracking Trends and Inequities With a Complete Contact-And-Content Index in Vietnam: 2011, 2014, and 2021 by Vu Thi Hoang Lan, Luisa N. Borrell, Bui Thi Tu Quyen, Hoang Van Minh, Pham Quang Duy, Victoria Ngo, Terry McGovern in Health Services Insights.
Author Contributions: V.T.H. Lan and L.N. Borrell conceptualized the study and developed the analytical plan. V.T.H. Lan drafted the first version of the manuscript. P.Q. Duy prepared the data. B.T.T. Quyen and P.Q. Duy performed the statistical analyses. All authors contributed to the interpretation of results, critically reviewed the manuscript and approved the final version for submission.
Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Supplemental Material: Supplemental material for this article is available online.
ORCID iDs
Vu Thi Hoang Lan https://orcid.org/0000-0001-8528-357X
Bui Thi Tu Quyen https://orcid.org/0000-0002-5061-8488
References
- 1.Van Minh H, Oh J, Hoat LN, Lee JK, Williams JS. Millennium Development Goals in Vietnam: Taking Multi-sectoral Action to Improve Health and Address the Social Determinants. Glob Health Action. 2016;9(1):31271. doi: 10.3402/gha.v9.31271. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Berhan Y, Berhan A. Antenatal Care as a Means of Increasing Birth in the Health Facility and Reducing Maternal Mortality: A Systematic Review. Ethiop J Health Sci. 2014;24(0 Suppl):93-104. doi: 10.4314/ejhs.v24i0.9s. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.UNICEF . Countdown to 2030 Country Profiles. UNICEF DATA; 2025. https://data.unicef.org/countdown-2030/. Accessed July 11, 2025. [Google Scholar]
- 4.General Statistics Office, UNICEF . Survey Measuring Viet Nam Sustainable Development Goal Indicators on Children and Women 2020-2021, Survey Findings Report. General Statistics Office; 2021. [Google Scholar]
- 5.Benova L, Tunçalp Ö, Moran AC, Campbell OMR. Not just a number: examining coverage and content of antenatal care in low-income and middle-income countries. BMJ Glob Health. 2018;3(2):e000779. doi: 10.1136/bmjgh-2018-000779. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Hodgins S, D’Agostino A. The quality-coverage gap in antenatal care: toward better measurement of effective coverage. Glob Health Sci Pract. 2014;2(2):173-181. doi: 10.9745/GHSP-D-13-00176. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Nguyen PT, Rahman MS, Le PM, et al. Trends in, projections of, and inequalities in reproductive, maternal, newborn, and child health service coverage in Vietnam 2000-2030: A Bayesian analysis at national and sub-national levels. Lancet Reg Health – West Pac. 2021;15:100230. doi: 10.1016/j.lanwpc.2021.100230. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Giles ML, Mason E, Muñoz FM, et al. Antenatal care service delivery and factors affecting effective tetanus vaccine coverage in low- and middle-income countries: Results of the Maternal Immunisation and Antenatal Care Situational analysis (MIACSA) project. Vaccine. 2020;38(33):5278-5285. doi: 10.1016/j.vaccine.2020.05.025. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Marsh AD, Muzigaba M, Diaz T, et al. Effective coverage measurement in maternal, newborn, child, and adolescent health and nutrition: progress, future prospects, and implications for quality health systems. Lancet Glob Health. 2020;8(5):e730-e736. doi: 10.1016/S2214-109X(20)30104-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Viet Nam General Statistics Office, UNICEF . Viet Nam Sustainable Development Goal Indicators on Children and Women Survey 2020–2021: Key Indicators. General Statistics Office; 2021. [Google Scholar]
- 11.Kassie AM, Eakin E, Endalamaw A, Zewdie A, Wolka E, Assefa Y. Effective coverage of maternal and neonatal healthcare services in low-and middle-income countries: a scoping review. BMC Health Serv Res. 2024;24(1):1601. doi: 10.1186/s12913-024-12085-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Arroyave L, Saad GE, Victora CG, Barros AJD. Inequalities in antenatal care coverage and quality: an analysis from 63 low and middle-income countries using the ANCq content-qualified coverage indicator. Int J Equity Health. 2021;20(1):102. doi: 10.1186/s12939-021-01440-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Dahab R, Sakellariou D. Barriers to Accessing Maternal Care in Low Income Countries in Africa: A Systematic Review. Int J Environ Res Public Health. 2020;17(12):4292. doi: 10.3390/ijerph17124292. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Hoang VM, Khuong QL, Nguyen TH, et al. Health financial hardship among ethnic minority populations in Vietnam. Asian Ethn. 2020;24:1-14. doi: 10.1080/14631369.2020.1846496. [DOI] [Google Scholar]
- 15.World Health Organization . WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience. World Health Organization; 2016. https://iris.who.int/handle/10665/250796 [PubMed] [Google Scholar]
- 16.World Health Organization . Neonates protected at birth against neonatal tetanus (PAB) (%): Indicator metadata registry details. 2020. https://www.who.int/data/gho/indicator-metadata-registry/imr-details/3207
- 17.Vu L, Tran B, Le A. The use of total assets as a proxy for socioeconomic status in northern Vietnam. Asia Pac J Public Health. 2011;23(6):996-1004. doi: 10.1177/1010539510361638. [DOI] [PubMed] [Google Scholar]
- 18.World Health Organization . Ending Preventable Maternal Mortality (EPMM): A Renewed Focus for Improving Maternal and Newborn Health and Well-Being. World Health Organization; 2021. https://www.who.int/publications/i/item/9789240040519. Accessed July 11, 2025. [Google Scholar]
- 19.Arsenault C, Jordan K, Lee D, et al. Equity in antenatal care quality: an analysis of 91 national household surveys. Lancet Glob Health. 2018;6(11):e1186-e1195. doi: 10.1016/S2214-109X(18)30389-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Silal SP, Penn-Kekana L, Harris B, Birch S, McIntyre D. Exploring inequalities in access to and use of maternal health services in South Africa. BMC Health Serv Res. 2012;12:120. doi: 10.1186/1472-6963-12-120. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplemental Material for Redefining Antenatal Care Coverage: Tracking Trends and Inequities With a Complete Contact-And-Content Index in Vietnam: 2011, 2014, and 2021 by Vu Thi Hoang Lan, Luisa N. Borrell, Bui Thi Tu Quyen, Hoang Van Minh, Pham Quang Duy, Victoria Ngo, Terry McGovern in Health Services Insights.