Viet Nam has experienced rapid social change over the last decade, with a remarkable decline in fertility to just below replacement level. The combination of fertility decline, son preference, antenatal sex determination using ultrasound and sex selective abortion are key factors driving increased sex ratios at birth in favour of boys in some Asian countries. Whether or not this is taking place in Viet Nam as well is the subject of heightened debate. In this paper, we analyse the nature and determinants of sex ratio at birth in Viet Nam, including a small family size norm, recent reinforcement by the Government of the “one-to-two child” family policy, traditional son preference, easy access to antenatal ultrasound screening and legal abortion, and an increase in the proportion of one-child families. In order to prevent an increased sex ratio at birth in Viet Nam, we argue for the relaxation of the one-to-two child family policy and a return to the policy of “small family size” as determined by families, in tandem with a comprehensive approach to promoting the value of women and girls in society, countering traditional gender roles, and raising public awareness of the negative social consequences of a high sex ratio at birth.