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Neonatal Mortality in Vietnam: Challenges and Effects of a Community-Based Participatory Intervention
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). (Internationell barnhälsa och nutrition/Persson)
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Globally neonatal mortality accounts for 40% of under-five deaths. Participatory interventions where the local problems are addressed have been successful in some settings.

The aim of this thesis was to describe challenges in perinatal health in a Vietnamese province, and to evaluate the effect of a facilitated intervention with local stakeholder groups that used a problem-solving approach to neonatal survival during three years.

The NeoKIP trial (Neonatal Knowledge Into Practice, ISRCTN44599712) had a cluster-randomized design (44 intervention communes, 46 control). Laywomen facilitated Maternal-and-Newborn Health Groups (MNHGs) and used Plan-Do-Study-Act cycles to address perinatal health problems. Births and neonatal deaths were monitored. Interviews were performed in households of neonatal deaths and randomly selected live births. Use of health services was mapped. The primary healthcare staff’s knowledge on newborn care was assessed before and after the intervention.

Neonatal mortality rate (NMR) was 16/1000 live births (variation 10 - 44/1000 between districts). Home deliveries accounted for one fifth of neonatal deaths, and health facilities with least deliveries had higher NMR. Main causes of death were prematurity/low birth-weight (37.8 %), intrapartum-related deaths (33.2 %) and infections (13.0 %). Annual NMR was 19.1, 19.0 and 11.6/1000 live births in intervention communes (18.0, 15.9 and 21.1 in control communes); adjusted OR 1.08 [0.66-1.77], 1.23 [0.75-2.01], and 0.51 [0.30-0.89], respectively. Women in intervention communes more frequently attended antenatal care, prepared for delivery and gave birth at institutions. Primary healthcare staff’s knowledge on newborn care increased slightly in intervention communes.

This model of facilitation of local stakeholder groups using a perinatal problem-solving approach was successful and may be feasible to scale-up in other settings.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2013. , 98 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 853
Keyword [en]
Facilitation, Local stakeholder group, Maternal-and-Newborn Health Group, Neonatal mortality, Primary health care, Vietnam
National Category
Medical and Health Sciences
Research subject
International Health
Identifiers
URN: urn:nbn:se:uu:diva-188252ISBN: 978-91-554-8567-2 (print)OAI: oai:DiVA.org:uu-188252DiVA: diva2:579372
Public defence
2013-02-05, Rosensalen, Akademiska Sjukhuset, Entrance 95/96 nbv, Uppsala, 09:15 (English)
Opponent
Supervisors
Projects
NeoKIP project in Vietnam
Available from: 2013-01-15 Created: 2012-12-14 Last updated: 2014-01-21Bibliographically approved
List of papers
1. Perinatal services and outcomes in Quang Ninh province, Vietnam
Open this publication in new window or tab >>Perinatal services and outcomes in Quang Ninh province, Vietnam
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2010 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 99, no 10, 1478-1483 p.Article in journal (Refereed) Published
Abstract [en]

Aim: We report baseline results of a community-based randomized trial for improved neonatal survival in Quang Ninh province, Vietnam (NeoKIP; ISRCTN44599712). The NeoKIP trial seeks to evaluate a method of knowledge implementation called facilitation through group meetings at local health centres with health staff and community key persons. Facilitation is a participatory enabling approach that, if successful, is well suited for scaling up within health systems. The aim of this baseline report is to describe perinatal services provided and neonatal outcomes. Methods: Survey of all health facility registers of service utilization, maternal deaths, stillbirths and neonatal deaths during 2005 in the province. Systematic group interviews of village health workers from all communes. A Geographic Information System database was also established. Results: Three quarters of pregnant women had >= 3 visits to antenatal care. Two hundred and five health facilities, including 18 hospitals, provided delivery care, ranging from 1 to 3258 deliveries/year. Totally there were 17 519 births and 284 neonatal deaths in the province. Neonatal mortality rate was 16/1000 live births, ranging from 10 to 44/1000 in the different districts, with highest rates in the mountainous parts of the province. Only 8% had home deliveries without skilled attendance, but those deliveries resulted in one-fifth of the neonatal deaths. Conclusion: A relatively good coverage of perinatal care was found in a Vietnamese province, but neonatal mortality varied markedly with geography and level of care. A remaining small proportion of home deliveries generated a substantial part of mortality.

Keyword
Home delivery, Inequity, Neonatal mortality, Perinatal care, Vietnam
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-135024 (URN)10.1111/j.1651-2227.2010.01866.x (DOI)000281556700013 ()
Available from: 2010-12-03 Created: 2010-12-03 Last updated: 2017-12-12Bibliographically approved
2. Causes of neonatal death: results from NeoKIP community-based trial in Quang Ninh province, Vietnam
Open this publication in new window or tab >>Causes of neonatal death: results from NeoKIP community-based trial in Quang Ninh province, Vietnam
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2012 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 101, no 4, 368-373 p.Article in journal (Refereed) Published
Abstract [en]

Aim: 

To ascertain the causes of neonatal death in a province in northern Vietnam and analyse their distribution over age at death, birth weight and place of delivery.

Methods: 

Verbal autopsy interviews using a questionnaire derived from WHO standard and adapted to Vietnamese conditions was performed on all neonatal deaths occurring in Quang Ninh province from July 2008 to June 2010. Three experienced paediatricians independently reviewed all verbal autopsy records (233) and assigned a main cause of death. In case of disagreement in the allocation of cause of death, a consensus process was initiated to decide on a final cause.

Results: 

Neonatal mortality rate within the study area was 16/1000 (238 neonatal deaths and 14 453 live births) over the study period. Prematurity/low birth-weight (37.8%), intrapartum-related neonatal deaths (birth asphyxia, 33.2%), infections (13.0%) and congenital malformation (6.7%) were the four leading causes of death. Four cases of neonatal tetanus were found. Intrapartum-related deaths dominated in the home delivery group, whereas prematurity was the most prominent cause of death at all facility levels. Most neonatal deaths occurred within the first 24 h after delivery (58.6%).

Conclusion: 

A high proportion of deaths due to prematurity and intrapartum-related causes, calls for improvements of delivery care and resuscitation practices at health facilities.

Keyword
Causes of death, Neonatal mortality, Verbal autopsy, Vietnam
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-164149 (URN)10.1111/j.1651-2227.2011.02513.x (DOI)000300973200021 ()22107114 (PubMedID)
Available from: 2011-12-16 Created: 2011-12-16 Last updated: 2017-12-08Bibliographically approved
3. Effect of Facilitation of Local Maternal-and-Newborn Stakeholder Groups on Neonatal Mortality: Cluster-Randomized Controlled Trial
Open this publication in new window or tab >>Effect of Facilitation of Local Maternal-and-Newborn Stakeholder Groups on Neonatal Mortality: Cluster-Randomized Controlled Trial
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2013 (English)In: PLoS Medicine, ISSN 1549-1277, E-ISSN 1549-1676, Vol. 10, no 5, e1001445- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND:

Facilitation of local women's groups may reportedly reduce neonatal mortality. It is not known whether facilitation of groups composed of local health care staff and politicians can improve perinatal outcomes. We hypothesised that facilitation of local stakeholder groups would reduce neonatal mortality (primary outcome) and improve maternal, delivery, and newborn care indicators (secondary outcomes) in Quang Ninh province, Vietnam.

METHODS AND FINDINGS:

In a cluster-randomized design 44 communes were allocated to intervention and 46 to control. Laywomen facilitated monthly meetings during 3 years in groups composed of health care staff and key persons in the communes. A problem-solving approach was employed. Births and neonatal deaths were monitored, and interviews were performed in households of neonatal deaths and of randomly selected surviving infants. A latent period before effect is expected in this type of intervention, but this timeframe was not pre-specified. Neonatal mortality rate (NMR) from July 2008 to June 2011 was 16.5/1,000 (195 deaths per 11,818 live births) in the intervention communes and 18.4/1,000 (194 per 10,559 live births) in control communes (adjusted odds ratio [OR] 0.96 [95% CI 0.73-1.25]). There was a significant downward time trend of NMR in intervention communes (p = 0.003) but not in control communes (p = 0.184). No significant difference in NMR was observed during the first two years (July 2008 to June 2010) while the third year (July 2010 to June 2011) had significantly lower NMR in intervention arm: adjusted OR 0.51 (95% CI 0.30-0.89). Women in intervention communes more frequently attended antenatal care (adjusted OR 2.27 [95% CI 1.07-4.8]).

CONCLUSIONS:

A randomized facilitation intervention with local stakeholder groups composed of primary care staff and local politicians working for three years with a perinatal problem-solving approach resulted in increased attendance to antenatal care and reduced neonatal mortality after a latent period.

TRIAL REGISTRATION:

Current Controlled Trials ISRCTN44599712

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-200236 (URN)10.1371/journal.pmed.1001445 (DOI)000319670900020 ()23690755 (PubMedID)
Available from: 2013-05-24 Created: 2013-05-23 Last updated: 2017-12-06Bibliographically approved
4. Effect of Facilitation of Local Maternal-and-Newborn Health Groups on Continuum of Perinatal Care: Results from the NeoKIP Trial in Northern Vietnam
Open this publication in new window or tab >>Effect of Facilitation of Local Maternal-and-Newborn Health Groups on Continuum of Perinatal Care: Results from the NeoKIP Trial in Northern Vietnam
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2012 (English)In: American Journal of Public Health, ISSN 0090-0036, E-ISSN 1541-0048Article in journal (Other academic) [Artistic work] In press
Abstract [en]

Background:

Continuum of maternal, delivery and newborn is a prerequisite for improved neonatal health and survival. This requires involvement from households, health system, and the society as a whole. In a community-based trial using facilitation of local perinatal health stakeholder groups in northern Vietnam neonatal mortality was reduced (NeoKIP trial; ISRCTN44599712). In this report we analyse the effect by the intervention on continuum of anternal, delivery, and newborn care. We also assess in perinatal health knowledge among primary health care staff in the area that could be associated with the intervention.

Methods:

The trial had a cluster-randomised design; 44 communes in Quang Ninh province were allocated to intervention and 46 to control. Laywomen recruited from Women’s Union facilitated monthly meetings during 3 years in groups composed by staff from health centres and key persons in the communes. A problem-solving approach was employed. Births and neonatal deaths were monitored. A sample of 6% all live births was randomly selected each month to represent the entire birth cohort. Mothers of these newborns were interviewed at home 8-10 weeks after delivery. Information was collected on use of antenatal, delivery, and postpartum health services. Primary healthcare staff was also interviewed assessing their knowledge on newborn care before and after the intervention. Results were compared between intervention and control communes.

Results:

Of the 22 377 live births occurring in the study area during the three years of trial, 1338 (5.9%) were randomly selected for home interview with the mothers. In total, 1243 interviews with mothers of surviving neonates were completed in intervention and control communes. Intervention and control areas were comparable in social characteristics. Coverage differed between intervention and control communes regarding antenatal care (difference 8.7 percent units, 95%CI 5.0-12.6) and most of its included service components, birth preparedness (difference 3.6 percent units, 0.2-7.0) and institutional delivery (difference 3.8, 0.3-7.4). Primary healthcare staff’s knowledge on newborn care also increased in intervention communes while there was no change in control communes.

Conclusions:

A community-based participatory intervention by facilitation of local stakeholder groups that resulted in decreased neonatal mortality was linked to small positive differences in continuum of maternal and neonatal care and in primary healthcare staff’s knowledge on newborn care. This may reflect the process of change in utilization of services and performance of services that ultimately lowered neonatal mortality in the area.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-187176 (URN)
Available from: 2012-12-20 Created: 2012-12-03 Last updated: 2017-12-06Bibliographically approved

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