The increased rice production in the Mekong Delta during the last two decades has improved agricultural income and reduced poverty, but it has also had negative impacts on the environment and human health. This study shows that integrated rice-fish farming and integrated pest management strategies provide sustainable options to intensive rice farming, because of a more balanced use of multiple ecosystem services that benefit the farmers' health, economy and the environment. The study investigates and compares farming strategies among 40 rice and 20 rice-fish farmers in two locations in the Mekong Delta. Production costs and income are used to compare the systems' financial sustainability. The farmers' perception on how their farming practices influence on ecosystem services and their livelihoods are used as an indication of the systems' ecological and social sustainability. Although rice-fish farmers used lower amount of pesticides and fertilisers than rice farmers, there were no statistical differences in their rice yields or net income. Rice was seen as the most important ecosystem service from rice fields and related wetlands, but also several other ecosystem services, such as water quality, aquatic animals, plants, habitats, and natural enemies to pests, were seen as important to the farmers' livelihoods and wellbeing. All farmers perceived that there had been a general reduction in all these other ecosystem services, due to intensive rice farming during the last 15 years, and that they will continue to decline. The majority of the farmers were willing to reduce their rice yields slightly for an improved quality of the other ecosystem services.