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JOURNAL OF SCIENCE, Hue University, N0 61, 2010
EVIDENCE FOR EFFECTIVENESS OF INTERVENTIONS IN NEWBORN
CARE: HAS DISTRICT NEWBORN CARE UNIT ADDRESSED NEWBORN
HEALTH PROBLEMS IN NHU THANH AND NGOC LAC HOSPITALS,
THANH HOA PROVINCE, VIETNAM?
Nguyen Van Hai
Save the Children
SUMMARY
Introduction: The Vietnamese health care system faces many challenges in ensuring the
survival of newborns with over 20,000 newborns still dying each year. The hierarchical health
system is not able to provide quality newborn care services. For example, district hospitals and
commune health centers are poorly equipped and have a lack of staff with adequate training in
essential newborn care, and management of newborn complications. Household-level newborn
care is provided through village health workers who lack standard communication materials,
training, supervision and monitoring. Misconceptions about newborn care at birth and
breastfeeding exist, especially in places with high rates of home births. Methods: This
Operation Research (OR) study consists of a comprehensive newborn care intervention package
which was introduced. The intervention included delivery care and postnatal care but more
effort was focused on immediate postnatal care and management of newborn complications. The
OR set four intermediate results (IRs): IR 1: Increased access and availability of newborn
services and supplies; IR 2: Improved quality of newborn care at health facilities; IR 3:
Enhanced community knowledge of newborn care practices and demand for newborn care
services; IR 4: Promotion of an enabling policy environment for scaling up newborn care. This
paper only covers facility-based interventions while other impacts will be reported at the end of
the project. Results: After 1.5 years of intervention, the OR has helped to significantly reduce
the neonatal mortality rate: 19.4%o (2006) to 14.4%o (2009) in Ngoc Lac, and 21.9%o (2006)
to 8.5%o (2009) in Nhu Thanh. The referral rate of newborn complications and home birth
rates also declined sharply in both districts. Conclusions: Neonatal deaths in Ngoc lac and Nhu
Thanh districts of Thanh Hoa province can be averted with low cost interventions through the
establishment of a district newborn care unit, and the health care system will benefit from
having a functional district newborn care unit.
Key words: neonatal death, district newborn care unit, facility-based intervention.
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1. Introduction
Vietnam is poised to achieve most, if not all, of its Millennium Development
Goals. Vietnam has already met the target of reducing the under-five mortality rate to 18
per 1,000 live births by 2015. However, the Vietnamese health care system faces many
challenges in ensuring the survival of newborns with over 20,000 newborn .deaths each
year. Neonatal deaths account for over 70% of the infant mortality rate, and varies
across 7 regions of Vietnam with the highest neonatal death rate occurring in the
northern mountainous and the northern central coast regions. One of the determinants is
poor access to newborn care in rural areas (geographic access, cultural barriers and
quality of care), where twice as many newborns die than in urban settings.
The hierarchical health system is not able to provide quality newborn care
services. Both district hospitals and commune health centers are poorly equipped and
staff lack adequate training in essential newborn care, and management of newborn
complications such as neonatal resuscitation, thermal care, and infections. Few CHCs
and district hospitals are capable of managing particular neonatal complications, and
most cases are referred to higher level facilities. This often results in unnecessarily
overloading provincial and central hospitals where only critical cases should be referred.
Many people also often bypass health services at commune health stations and
district hospitals and go directly to higher- level facilities, because they lack confidence
in the competence of services provided at lower-level facilities. This may result in
aggravating the condition of newborns during transportation, as they may not receive
proper care for some manageable situations, such as attending to the newborn’s body
temperature. This situation also results in families spending more money, and increased
human resources to care for the newborns in the hospital.
There is a severe shortage of essential equipment for newborn care in all district
hospitals. Only 21.9% of district hospitals are equipped with a set of appropriate
newborn resuscitation equipment (UNFPA, 2003) while most commune health centers
have no essential newborn resuscitation equipment. In fact, there is no unified neonatal
care model for the provincial and district level, thus most of these facilities are facing
difficulties in providing services for newborns, especially sick newborns. Consequently,
there is a gap in newborn deaths caused by preventable conditions. At the household
level, there are some misconceptions about newborn care at birth and breastfeeding,
especially in places where the home birth rate is high.
An annual report from the Thanh Hoa provincial center for reproductive health
care indicates that its annual neonatal mortality rate is 4%, which is lower than other
developed countries like Singapore, the Unites States and England (5%o). This means
that the reported data is somehow underestimated. A baseline survey (2007) in Ngoc
Lac and Nhu Thanh, Thanh Hoa indicates that the neonatal mortality rate in Ngoc Lac is
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19.4%o, and Nhu Thanh 21.9%o. The home birth rate is 24% (Ngoc Lac) and 30% (Nhu
Thanh) respectively.
In short, Thanh Hoa – similar to situation throughout Vietnam – is facing huge
challenges in addressing newborn health problems: lack of a functional newborn care
system from community to district level; severe shortage of trained health workers in
newborn care; absence of infrastructure, and appropriate equipment for newborn care at
commune and district level; a high prevalence of home delivery; the community’s
knowledge of newborn care is limited, and misconceptions about newborn care at home,
and lack of information about breastfeeding, especially in places where home delivery is
high.
2. Methods
Design: This is an operation research (OR) study with simple pre-and-post
intervention comparison. However, this paper is only an abstract report from
preliminary findings of the district newborn care unit within the comprehensive
intervention package.
Location: Thanh Hoa province is 157 km southward from Hanoi, with a natural
land area of 11,106 km2. The province possesses a diversified topography with 75% of
its land are mountainous and midland area, 15% lowland and 10% coastal. It has a
population of 3.7 million inhabitants living and working in 27 districts, towns and
Thanh Hoa city, 636 communes and 7 ethnic groups including: Kinh, Muong, Thai,
H’Mong, Dao, Tho and Hoa. These ethnic groups reside mainly in mountainous and
bordering districts.
Nhu Thanh and Ngoc Lac districts were selected in the OR. These are
mountainous districts with a total population of 226,663 people, and the total number of
deliveries is nearly 3,000 per year. They have 39 communes and 474 villages. There are
about 17 remote and especially disadvantaged communes. Below are key health
indicators for Nhu Thanh and Ngoc Lac districts:
Table 1. Key health indicators of Nhu Thanh and Ngoc Lac (2007)
Source: *Reports from neonatal death screening in Thanh Hoa, March 2007
Indicators Nhu Thanh Ngoc Lac
Population 85,227 141,436
Number of communes 17 22
Neonatal death rate (%o) 21.9* 19.4*
Delivery in health facility (%) 70 76
Home delivery rate (%) 30 24
Number of delivery per year 1,078 1,876
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3. Result
3.1. Results framework
This OR consists of a comprehensive newborn care intervention package
including delivery care and postnatal care, but more effort will be focused on immediate
postnatal care and management of newborn complications. The project has set four
intermediate results (IRs). IR 1: Increased access and availability of newborn services
and supplies; IR 2: Improved quality of newborn care at health facilities; IR 3:
Enhanced community knowledge of newborn care practices and demand for newborn
care services; IR 4: Promotion of an enabling policy environment for scaling up of
newborn care. The OR study will address the continuum of care from household-to-
hospital with interventions implemented by government staff and volunteers.
The study is designed to demonstrate to policy makers, health managers, and
authorities that quality newborn health care service can be provided with a small
investment even in resource-poor settings. It will also show that quality services along
with improved household practices will lead to improved newborn health outcomes.
However, this paper will only refer to facility-based interventions (IR1 and IR2).
The Results Framework is graphically shown below.
Data collection: Data collection tools were designed carefully in order to capture
all information about newborn care and newborn complications in two selected districts.
Information collection relied on the government existing reporting system with village
health workers in the community, CHC staff at the communal level and functional
newborn care unit, and the district health center at the district level. However, this
system was optimal because it provided designated data collectors with formatted
registers and forms, which facilitated them to fill out and reconcile the data. To validate
the intervention package, a Monitoring and Evaluation (M&E) Plan was designed.
