Background: The number of childbearing adolescents in Vietnam is relatively low but they are more prone to experience adverse outcome than adult women. Reports of increasing rates of abortion and prevalence of STIs including HIV among youth indicate a need to improve services and counselling for these groups. Midwives are key persons in the promotion of young people’s sexual and reproductive health in Vietnam. Aim: The overall aim of this thesis is to describe the prevalence and outcome of adolescent pregnancies in Vietnam (I), to explore the social context and health care seeking behavior of pregnant adolescents (II), as well as to explore the perspectives of health care providers and midwifery students regarding adolescent sexuality and reproductive health service needs (III, IV). Methods: The studies were conducted from 2002 to 2005, combining qualitative and quantitative research methods. A population based prospective survey was used to estimate rates and outcomes of adolescent pregnancies (I). Pregnant and newly delivered adolescents’ experiences of childbearing and their encounters with health care providers were studied using qualitative interviews (II). Health care providers’ perspective on adolescent sexual and reproductive health (ASRH) and views on how to improve the quality of abortion care was explored in focus group discussions (FGD). The values and attitudes of midwifery students about ASRH were investigated using questionnaires and interviews (IV). Descriptive statistics was used to analyse quantitative data (I, IV) and content analysis were applied for qualitative data (II, III, and IV). Findings: Adolescent birth rate was similar to previously reported in Vietnam but lower when compared to other Asian countries. The incidence of stillborn among adolescents was higher than for women in higher reproductive ages. The proportion of preterm deliveries was 20 % of all births, higher than previous findings from Vietnam. About 2 % of the deliveries were home deliveries, more common among women with low education, belonging to ethnic minority and/or living in mountainous areas (I). Ambivalence facing motherhood, pride and happiness but also worries and lack of self-confidence emerged as themes from the interviews; and experience of ‘being in the hands of others’ in a positive, caring sense but also in a sense of subordination in relation to husband, family and health care providers (II). Health care providers at abortion clinics and midwifery students generally disapproved of pre-marital sex, but had a pragmatic view on the need for contraceptive services and counselling to reduce the burden of unwanted pregnancies and abortions for young women. Providers and midwifery students expressed a need for training on ASRH issues (III, IV). Conclusion: Cultural norms and gender inequity make pregnant adolescent women in Vietnam vulnerable to sexual and reproductive health risks. Health care providers experience ethical dilemmas while counselling unmarried adolescents who come for abortion and this has a negative impact on the quality of care. Integrated ASRH in education and training programmes for health care providers, including midwives, as well as continued in-service training on these issues are suggested to improve reproductive health care services in Vietnam.

Midwifery is a dynamic, ever changing, specialised field of nursing involving the care of women and childbearing families. Clients are central to the practice of midwifery and thus their well-being is the main focus of midwives. So, it is not surprising that much of the relatively small body of midwifery research is client focused. As a result, client perspectives have been studied in a number of ways, regarding several aspects of midwifery care. This research, however, aimed to consider midwifery from the midwives' perspective by exploring the everyday encounters of everyday midwives who are working in institutional settings, and identifying the ethical aspects of those encounters. From the researcher's standpoint, it is clear that midwives' everyday encounters are ethical encounters and have potential to be either beneficent or harmful. There was, however, uncertainty that midwives recognized this "everydayness" of ethics. This research sought to clarify the place of ethics within midwives' everyday activities. A further purpose was to ascertain how the ethics that entered into the encounters and activities midwives participated in on a daily basis had affected their practise, their profession and/ or themselves. In doing this, the intent was to broaden the understandings of the ethical dimension of the practice. A particular ethical approach was adopted for this project. It is a view of ethics where persons have regard for, and responsibility toward, each other (Isaacs, 1998). The fact that midwifery is a social practice was expected to be significant in both the everyday encounters that midwives experienced and the ethical responses to those encounters. Members of social practices share an overall purpose and have a moral obligation or desire to practise ethically. As they share a culture and a covenantal commitment to care for those the profession seeks to serve - in a context of gift, fidelity and trust (Isaacs, 1993; Langford, 1978), it was anticipated that midwives would, generally, work in an ethically laden "world". Narrative research offered an appropriate framework for investigating these dimensions of midwifery practice. Many authors have noted the value of story-telling for making sense, and illuminating the ethical features, of our lives. It is, Kearney says, "an open-ended invitation to ethical ... responsiveness" (2000, p. 156). By enabling the participants to tell their stories, rich, contextual narrative material was obtained. The researcher was able to engage with both the participants and the stories as audience. An introduction to the study is provided in Chapter One, while Chapter Two explains both why narrative inquiry was chosen for this research project and the framework that was utilised. The insights from the study are presented in Chapters Three through Six. Each chapter considers the issues and concepts arising from stories that involve midwives' relationships and interactions with a different group of people: midwives, institutions and administration ("them"), doctors and families. In Chapter Three different types of interactions between midwives and their colleagues are explored. Some of the issues that arise are the importance of understanding one's own values and the place of ethics in practice, as well as the need to "do ethics-on-the-run". Many ethical concepts are evident including autonomy, integrity and professional identity. Participants had many negative experiences, and some conveyed feeling a lack of support, threatened or overwhelmed. Conversely, some stories share very positive images of mutual understanding where midwives worked together empathetically. Chapter Four looks at how managers' interactions with midwives impacted upon them and their practice. Unfortunately, this seems to be mostly negative. The midwives convey a sense of feeling undervalued both professionally and personally. Doctors have their turn to interact with the midwives in Chapter Five. In this chapter it becomes evident that doctors and midwives view birth from different perspectives. The participants' stories tell of challenging situations that alert us to the fact that normal, in the context of birth, is not as simple and common place as one might think when doctors and midwives have to work together. Wonderful, positive stories of midwives and doctors working together told of the symbiotic relationship that these two groups of professionals can have when the client is the focus. The last of the insights chapters, Chapter Six, focuses on the relationships midwives have with families. Interestingly, these are the people they spoke of least, even though they are the people for whom the profession exists. Here the concept of midwife as friend is discussed. Then, through their stories some of the participants help us to learn how midwives work together with their clients, care about them, not just for them, and how their past experience has had a lasting impact on their practice. Professionalism (or a lack of it) was implicated as a possible cause of some of the participants' concerns, as was the improper use of power. Both of these concepts arose many times throughout the project. Chapter 7 discusses these issues in some depth. The final chapter provides an overview of midwives situated within their practice. An account is offered of how the participants see the future of their practice and it is questioned if midwifery is, in fact, a social practice with common goals. The thesis draws attention to the embeddedness of ethics in the everyday practice of midwives, and to the vital role that relationships play in midwifery practice. This suggests the need for a relational, contextual ethics approach if the practice is to flourish.