152153
JOURNAL OF SCIENCE, Hue University, N
0
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:

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 155
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

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 1,876 156
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

supervision

Service quality
improvement
(COPE)…

Develop and
distribute IEC
materials on NBC
ToT courses on BCC
for province and
district trainers
Advocacy efforts to
implement the
scaling-up plan.

Scale-Up of OR
intervention package.

Roll-out BCC
training courses for
commune and village
staff…

Processes/Activities
Develop nat. standards/
guidelines, action plan,
and training manuals

Goal

community- level
understanding and
acceptance of using
healthy NBC
practices
Intermediate
result 4
Strengthened
enabling
environment for
newborn survival

Outputs Outcomes
Impact
SAVING NEWBORN LIVES (SNL) RESULTS FRAMEWORK 158

DH

Central Project Management
Board
(Save the Children – MoH)

VHW

VHW

VHW

Commune Health Centers
General Pla
nning Dept
of DH and
District Health Center
Monthly Monthly Monthly Quarterly

Central Project Management
Board
(Save the Children – MoH)

FREQUENCY
LEVEL
NBC Unit
of DH

Obstetrics
Dept, DH

equipment for newborn care and integrated newborn care between the obstetric and
pediatric specialty, and human resources. With a functional referral system (community
to district), all newborns with complications in two districts were given care and
transferred to either commune health centers (first point of contact) or the district
newborn care unit for timely management and treatment.
There was a big change in the number of newborn admissions to district hospital
since the birth of the district newborn care unit – October, 2008 (Table 2).
Table 2. Situation of newborn complications at pre & post intervention periods
Indicator
Pre-intervention (2006)
Preliminary results
(2008-2009)
Ngoc Lac Nhu Thanh Ngoc Lac Nhu Thanh
# newborn admission to
district newborn care unit

N/A N/A 867 215
Treatment outcomes
Cured N/A N/A 767 178
Referred to higher level N/A N/A 79 32
Dead N/A N/A 13 2
Request to go home N/A N/A 34 3
Collaboration between pediatric and obstetric departments in newborn care have
improved and been implemented in a systematic manner. Before intervention, most
newborn health problems were handled by the obstetric department. However since then
newborn care unit was established, located at the pediatric department. All deliveries
suspected of difficulties had a joint consultation with obstetric and pediatric staff. If
complications were predicted, the newborn health would be handled by well-trained
- Ngoc Lac
- Nhu Thanh

95% (25%)*
98% (24%)*

10.8%
14.2%
3
Home delivery
- Ngoc Lac
- Nhu Thanh

23.9%
30%

12.1%
7.7%
4
Institution delivery
- Ngoc Lac
- Nhu Thanh

76.1%
70%

87.9%
92.4%
After 1.5 years of intervention, the Operation research has helped to reduce
significantly the neonatal mortality rate: 19.4%o (2006) to 14.4%o (2009) in Ngoc Lac,

 Help to improve management of all neonatal cases in the district through
the information system at the newborn care unit.
 Create the availability of services to meet the people’s need for health
care.
Benefits for community
 Place credit to hospital when seeking care
 Reduce non-medical costs (food, transportation, accommodation, etc…)
and medical costs of bypassed patients at higher levels.
 Convenient for patients when seeking care in the district hospitals due to
shorter distance travel between the hospital and their home.
 Care givers are provided with information about newborn care at home.
 Lives and health of the newborns are taken care because of available
well-trained health workers. 162
Success story: Bravo for the Newborn Care Unit warmer!

(Anecdote from Mrs. Quách Thị Thương in Rộc Môn village, Mậu Lân commune, Như Thanh
district)
Twenty-year old Quách Thị Thương, an ethic
Mường, was in her 35
th
week of pregnancy with twins
when she felt severe abdominal pain. At around 8PM, her
family took her from Rộc Môn village to the Mậu Lân
Commune Health Centre by motorbike. It took them 30
minutes to reach the Commune Health Center. The
commune health workers assessed her and identified signs
that indicated she was likely to have a difficult and early

This report was made to document preliminary results from the performance and
operation of district newborn care unit. Overall, the performance of district newborn
care unit has actually improved health outcomes of newborns in the two intervention
districts. Before the intervention was made, there was no functioning newborn care unit
at district level, thus all newborn health problems were handled by obstetric department
(for delivery at district hospital). As most district health workers were not trained in
newborn care and newborn complications management, almost all newborn
complications were referred to either provincial or national hospital.
About 89% (Ngoc Lac) of newborn complications was treated successfully,
while it was 83% in Nhu Thanh. A salient point that should be discussed here is:
“Requests to go home” (4% in Ngoc Lac and 1.4% in Nhu Thanh). These cases were
too serious or the babies were too small and weak (pre-term birth), thus the newborn
care unit was not able to save their lives. Going home meant that they would die at
home.
While the number of newborn admission to the district newborn care unit was
restricted to deliveries in hospital and referral cases to the district hospital (facility-
based), neonatal death figures captured information from both health facility and
community (reported by village health workers using the designed health information
system). Given this reporting system, it is guaranteed that 100% of newborn deaths are
captured in this system.
The birth of the district newborn care unit has brought about not only medical
benefits but also non-medical benefits. The linkage in newborn care across clinical
levels has helped the health system to function more smoothly, helping reduce pressure
of newborn care at higher levels. On one hand, the newborn care unit has created
availability of services for the catchments area and vicinity. It also helps establish a
teaching facility for a communal health center with low training costs as commune
health staff don’t have to travel long distance to learn neonatal care skills. On the other
hand, local people find it convenient to seek care at the district hospital without having
to pay for non-medical costs and other opportunities costs.
Although we did not have information about revenue from newborn care

with positive health outcomes); and brought about huge non-health benefits for
community (reducing medical and non-medical, and opportunity costs for local people.
Overall, the performance of district NBC unit has actually improved health outcomes of
newborns in 2 intervention districts, and brought about great benefits for the local
community, health care providers and administrators.
REFERENCES
1. Save the Children: Baseline household survey on newborn care in Nhu Thanh and
Ngoc Lac district, Thanh Hoa province (2007)
2. Baseline survey report, UNFPA, 2003
3. Save the Children: Health facility and staff assessment in newborn care in Nhu
Thanh and Ngoc Lac district, Thanh Hoa province (2007)
4. Ministry of Health: A situational analysis of newborn health and intervention in
Vietnam (2006)
5. Save the Children: Screening of neonatal death in Ngoc Lac and Nhu Thanh, Thanh
Hoa (2007)
6. UNICEF: The State of the World’s Children 2009 (New York: United Nations
Children’s Fund)