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Who can save the unseen?: Studies on neonatal mortality in Quang Ninh province, Vietnam
Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kvinnors och barns hälsa, Internationell mödra- och barnhälsovård (IMCH).
2010 (Engelska)Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
Abstract [en]

Globally, neonatal mortality has remained basically unchanged for the last three to four decades and every year almost four million newborns die before reaching one month of age. This persistent mortality is related to an invisibility of the newborn child in policies and statistics and a neglect of health care decision-makers, planners and practitioners to deliver a perinatal continuum of care. In recent years attention has however been brought to the unchanged neonatal mortality in an effort to improve survival.

The present thesis seeks to increase understanding of obstacles for better neonatal survival. The studies performed are undertaken as sub-studies to the NeoKIP project in Quang Ninh province in northern Vietnam, a randomized controlled trial of knowledge implementation for improved neonatal survival (Neonatal Health – Knowledge Into Practice, ISRCTN 44599712). In the first paper we investigated and discussed the scope of invisibility of neonatal mortality through measuring the accuracy of official statistics on neonatal deaths. The second paper reports an inquiry of determinants of neonatal mortality by use of a population-based case-referent design. Paper III and IV analyse delivery care utilization and care seeking patterns prior to and at delivery using narratives and GIS technique.

There was a substantial under-reporting of neonatal mortality in the official statistics, with study results showing a four times higher neonatal mortality rate in Quang Ninh province than reported to the Ministry of Health. This neonatal mortality rate of 16/1000 live births (as compared to 4.2/1000 in official reports) was unevenly distributed in the province, showing large geographical discrepancies. In the rural and remote areas of Vietnam education level is lower and the concentrations of ethnic minorities and poor households are higher. Ethnic minority belonging was associated with a more than doubled risk of neonatal death compared to the hegemonic group of Kinh (OR 2.08 CI 95 % 1.39 – 3.10). This increased risk was independent of household economic status or maternal education level. Neonatal mortality was also associated with home deliveries, non-attendance to antenatal care and distance to the health care facilities. However, ethnic minority mothers still had an increased risk of experiencing a neonatal death even if they attended antenatal care, delivered at or lived close to a health facility.

The invisibility of the neonatal period in health information systems hides the true width of the neonatal mortality challenge. By not acknowledging the problem, the marginalization of already disadvantaged groups continues, leaving ethnic minority babies with an elevated risk of dying during the first month in life. This example of ethnic inequity highlights the importance to target those most in need. The studies of the present thesis should therefore be looked upon as a contribution to the struggle to illuminate the global burden of neonatal mortality.

Ort, förlag, år, upplaga, sidor
Uppsala: Acta Universitatis Upsaliensis , 2010. , s. 74
Serie
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 587
Nyckelord [en]
Neonatal mortality, Inequity, Ethnic minorities, Care seeking, Delivery care utilization, Under-reporting, Vietnam
Nationell ämneskategori
Pediatrik
Forskningsämne
Internationell hälsa
Identifikatorer
URN: urn:nbn:se:uu:diva-129242ISBN: 978-91-554-7867-4 (tryckt)OAI: oai:DiVA.org:uu-129242DiVA, id: diva2:338095
Disputation
2010-10-08, Rosénsalen, Ing 95/96, Akademiska sjukhuset, Uppsala, 09:15 (Engelska)
Opponent
Handledare
Tillgänglig från: 2010-09-10 Skapad: 2010-08-10 Senast uppdaterad: 2010-09-10Bibliografiskt granskad
Delarbeten
1. Unreported births and deaths, a severe obstacle for improved neonatal survival in low-income countries; a population based study
Öppna denna publikation i ny flik eller fönster >>Unreported births and deaths, a severe obstacle for improved neonatal survival in low-income countries; a population based study
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2008 (Engelska)Ingår i: BMC International Health and Human Rights, ISSN 1472-698X, E-ISSN 1472-698X, Vol. 8, s. 4-Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

ABSTRACT: BACKGROUND: In order to improve child survival there is a need to target neonatal mortality. In this pursuit, valid local and national statistics on child health are essential. We analyze to what extent births and neonatal deaths are unreported in a low-income country and discuss the consequences at local and international levels for efforts to save newborn lives. METHODS: Information on all births and neonatal deaths in Quang Ninh province in Northern Vietnam in 2005 was ascertained by systematic inventory through group interviews with key informants, questionnaires and examination of health facility records. Health care staff at 187 Community Health Centers (CHC) and 18 hospitals, in addition to 1372 Village Health Workers (VHW), were included in the study. Results were compared with the official reports of the Provincial Health Bureau. RESULTS: The neonatal mortality rate (NMR) was 16/1000 (284 neonatal deaths/17 519 births), as compared to the official rate of 4.2/1000. The NMR varied between 44/1000 and 10/1000 in the different districts of the province. The under-reporting was mainly attributable to a dysfunctional reporting system and the fact that families, not the health system, were made responsible to register births and deaths. This under-reporting has severe consequences at local, national and international levels. At a local level, it results in a lack of awareness of the magnitude and differentials in NMR, leading to an indifference towards the problem. At a national and international level the perceived low mortality rate is manifested in a lack of investments in perinatal health programs. CONCLUSION: This example of a faulty health information system is reportedly not unique in low and middle income countries where needs for neonatal health reforms are greatest. Improving reporting systems on births and neonatal deaths is a matter of human rights and a prerequisite for reducing neonatal mortality in order to reach the fourth millennium goal.

Nyckelord
neonatal mortality, child health
Nationell ämneskategori
Medicin och hälsovetenskap
Identifikatorer
urn:nbn:se:uu:diva-98173 (URN)10.1186/1472-698X-8-4 (DOI)18373839 (PubMedID)
Tillgänglig från: 2009-02-16 Skapad: 2009-02-16 Senast uppdaterad: 2017-12-13Bibliografiskt granskad
2. Ethnic inequity in neonatal survival: a case-referent study in northern Vietnam
Öppna denna publikation i ny flik eller fönster >>Ethnic inequity in neonatal survival: a case-referent study in northern Vietnam
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2011 (Engelska)Ingår i: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 100, nr 3, s. 340-346Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Aim: In this study from Quang Ninh province in northern Vietnam (sub-study of the trial Neonatal Health - Knowledge into Practice, NeoKIP, ISRCTN 44599712), we investigated determinants of neonatal mortality through a case-referent design, with special emphasis on socio-economic factors and health system utilization. Methods: From July 2008 until December 2009, we included 183 neonatal mortality cases and 599 referents and their mothers were interviewed. Results: Ethnicity was the main socio-economic determinant for neonatal mortality (OR 2.08, 95% CI 1.39-3.10, adjusted for mothers' education and household economic status). Health system utilization before and at delivery could partly explain the risk elevation, with an increased risk of neonatal mortality for mothers who did not attend antenatal care and who delivered at home (OR 4.79, 95% CI 2.98-7.71). However, even if mothers of an ethnic minority attended antenatal care or delivered at a health facility, the increased risk for this group was sustained. Conclusion: Our study demonstrates inequity in neonatal survival that is related to ethnicity rather than family economy or education level of the mother and highlights the need to include the ethnic dimension in the efforts to reduce neonatal mortality.

Nyckelord
Equity, Ethnic Inequity, Ethnicity, Neonatal mortality, Vietnam
Nationell ämneskategori
Medicin och hälsovetenskap
Forskningsämne
Epidemiologi
Identifikatorer
urn:nbn:se:uu:diva-129209 (URN)10.1111/j.1651-2227.2010.02065.x (DOI)000286837700009 ()20958789 (PubMedID)
Tillgänglig från: 2010-08-10 Skapad: 2010-08-09 Senast uppdaterad: 2018-11-28Bibliografiskt granskad
3. Delivery care utilisation and care-seeking in the neonatal period: a population-based study in Vietnam
Öppna denna publikation i ny flik eller fönster >>Delivery care utilisation and care-seeking in the neonatal period: a population-based study in Vietnam
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2008 (Engelska)Ingår i: Annals of Tropical Paediatrics, ISSN 0272-4936, E-ISSN 1465-3281, nr 28, s. 191-198Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Background: If millions of neonatal deaths each year are to be prevented, one crucial component that must be improved is adequate care-seeking behaviour and effective use of existing health care systems. We have investigated these factors in relation to delivery and the neonatal period in a province in Northern Vietnam, a setting currently in socio-economic transition.

 

Methods: Information on births and neonatal deaths between January and December 2005 in Quang Ninh province was collected. Narratives of the neonatal deaths were gathered and information about care-seeking in relation to delivery and illness was extracted. This information was then compared with the time and place of delivery and death.

 

Results: We registered 17,519 births and 284 neonatal deaths occurring between January and December 2005. The neonatal mortality rate varied from 7.5/1000 to 38/1000, depending on the place of delivery. A quarter of the neonatal deaths had no contact with the health-care system at the time of death. Neonatal death within 24 hours of birth was more likely when the mother did not seek care at the time of delivery, or did so at the lowest level of the system (χ2 = 35.5, p<0.001). Mothers of ethnic minorities were more likely to exhibit this care-seeking behaviour at delivery.

 

Conclusion: Further improvement in neonatal survival can be achieved by changes in health system utilisation that aim to secure safe delivery for pregnant women. More efforts at local level are needed to encourage adequate care-seeking.

Nationell ämneskategori
Medicin och hälsovetenskap
Identifikatorer
urn:nbn:se:uu:diva-87358 (URN)10.1179/146532808X335633 (DOI)000259640600002 ()
Tillgänglig från: 2008-11-27 Skapad: 2008-09-24 Senast uppdaterad: 2017-12-13Bibliografiskt granskad
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