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Researches Community health care

 Trần Chí Liêm*, Lê Quang Cường, Nguyễn Duy Khê**, Trần Thị Mai Oanh,

Lưu Thị Hồng**, Đinh Thị Phương Hòa**, Phan Hồng Vân et al.

* Ministry of Health;  ** Department of Maternal and Child Health, MOH
Place of publication: Ministry of Health
Year of publication: 2011

The survey on maternal and newborn mortality in Vietnam period 2006-2007 is carried out in April and May 2009 with the objectives: (1) Identify maternal mortality rate (MMR), newborn mortality rate (NMR) in Vietnam in 2006-2007, compare the difference between mountainous and plain areas; (2) Describe direct, indirect causes and factors related to MMR and NMR in Vietnam, compare the difference between mountainous and plain areas; and (3) Make recommendations to reduce MMR and NMR in Vietnam.

The study is conducted in all communes of 30 districts in 10 provinces/cities with the ratio of rural mountainous /plain /urban districts = 16/10/4. This is the nationally representative sample size.
The study has collected and consolidated data on female mortality in 15-55 age group from different sources (vital logbook of commune health centers, public and private health facilities, population sector, justice sector and community group discussion) and employed the RAMOS – a method to survey mortality among women in reproductive ages. After firmly identifying maternal mortality cases, the relative of passed-away women, witnessed health care professionals are interviewed using verbal autopsy questionnaires. Information generated from these questionnaires and mortality record retrospection help experts to identify mortality causes and influencing factors. 

Key study results
According to study results, data collected via survey in combination with information from various sources reveal the differences from statistics provided by localities. Specific results are as follows. 
Female mortality
- Results show that there is a total of 1,196 women aged 15-49 years old identified as death during the previous period in surveyed locations, of which the additionally detected cases number 299 (an increase of 33.33% compared with local statistics).
The general female mortality rate in 15-49 age group in the total samples is 0.72%o. There are differences among geographical areas: the rural mountainous has the highest rate (0.76%o), followed by rural plain (0.69%o) and lowest in urban areas (0.66%o).
- The survey discovers 1,196 female mortality cases, of which 49 are maternal mortality. The MMR over general female mortality of 15-49 age group is 4.10%.
Maternal mortality
Of 49 maternal mortality cases, 18 are reported by localities as maternal mortality and 12 as female mortality and 19 newly detected during field survey. By geographical areas, there are 35 maternal mortality cases (71.4%) in rural mountainous, 9 cases (18.4%) in rural plain and 5 others (10.2%) in urban areas.
According to direct survey results, the MMR in Vietnam is 46/100,000 live births in 2006-2007. According to results after power calculation, the MMR in Vietnam is 42/100,000 live births in 2006-2007, confidence interval ranges 23 – 61. According to WHO recommendations for RAMOS survey on MMR, the generally adjusted MMR for the whole nation is 63/100,000 live births in 2006-2007, confidence interval ranges 42 - 84. Data adjusted according to WHO recommendations will be used as official figures.
About 80% maternal mortality cases have education below secondary level. About 60% of them are farmers.
- Most maternal mortality cases (42.9%) happen after pregnancy termination and during pregnancy termination (34.7%). Only about 22.4% maternal mortality cases take place before pregnancy ending.
Most maternal mortality cases deliver birth at hospital. Only one third of them deliver at home. - Most of mortality cases happen at hospital (62.5%), of which 40% at provincial hospital, 16% at district hospital and 6.5% at central hospital.
- 71.5% maternal mortality cases are due to direct causes and 16.3% due to indirect ones. Direct causes include bleeding (34.7%), eclampsia (18.4%) and infection (14.3%), only 4.1% due to amniotic fluid embolism. There remains 12.2% maternal mortality cases without identified causes.
Factors contributing to maternal mortality consist of:
late in making decision on access to quality health facilities in all areas, especially in the mountain;
non-availability of patient transport means and difficult transport conditions, leading to high rate of birth delivery at home – a factor helping to increase maternal mortality;
untimely emergency and treatment;
limited technical capacities, physical infrastructure, care services;
extremely limited habit and knowledge in mountainous areas. 
Newborn mortality
The survey has identified there are 341 newborn mortality cases /54,602 live births in the 2007 samples: 214 (53.3%) mountainous, 88 (33.3%) plain and 39 (13.3%) urban areas.
The national general newborn mortality rate (NMR) is 7.0/1,000 live births (5.0-9.0). Highest NMR is seen in mountainous area, at 10.0/ 1,000 live births. In plain area, it is 5.0/1,000 live births and lowest is in urban areas, at 4.0/1,000 live births.
Premature/underweight birth is the leading cause of NMR (38,1%), applicable to all geographical areas. Suffocation ranks second (24.9%) in urban and mountainous areas whereas it is very low in plain areas. Infection ranks third (15.8%), mainly in mountainous areas. Inborn defects, heart abnormalities rank 4th (8.8%) in NMR.
Among factors related to NMR, first is lack of knowledge and backward (28.9%), especially in the mountainous. Follow is home birth delivery (20%), also mainly in the mountainous areas. Third is late emergency and referral (mainly in the mountainous areas) and far distance from home to health facilities (especially in mountainous areas).

Data collected from the survey in combination with information from different sources show a great variance with locally reported statistics. The survey discovers an addition of 19 maternal mortality cases (post-survey actual number of 49). With regard to newborn mortality, according to locally reported statistics there are 400 cases. However according to survey results there are only 341 cases and the remaining 59 are mistaken with still birth or infant mortality.
The MMR and NMR reduced significantly in the past 5 years. MMR falls from 165 (in 2001-2002) to 63 (2006-2007)/100,000 live births. NMR drops from 12.2 (in 2002) to 7.0 (in 2007)/1,000 live births. However there remain inequality among regions. In mountainous areas, the maternal mortality risk is 3 times higher and that of newborn is 2-2.5 times higher than other areas.
The causes of maternal and newborn mortality remain unchanged, similar to previous surveys and alike countries. The leading cause of maternal mortality is bleeding. The leading cause of newborn mortality is premature/underweight birth. Nonetheless this study does not discover abortion as a cause of maternal mortality. This may suggest that the Vietnamese women have access to complete and safer abortion methods.
Factors related to maternal and newborn mortality are three late, namely (1) lack of knowledge leading to late decision making on right choice to quality health care services, (2) non-availability of transport means and difficult transport leading to late access to quality health facilities, and (3) untimely emergency, referral and treatment.
It is needed to improve the quality of the existing data collection system.
Separate survey for newborn should be conducted with optimal survey method to minimize missing or mistaken cases to have accurate statistics of newborn mortality for the whole nation.
Data should be regularly collected via survey or establishment of a surveillance system on maternal and newborn mortality data to have accurate figures, helping the process of health planning and policy making.
The general maternal and newborn mortality reduced in the last 5 years but there remain inequality among regions and areas. The risks of maternal and newborn mortality in the mountainous areas are 2-3 times higher over others. Mortality cases focus among farmers, who have low income in the community. This shows that there should be concrete policies and appropriate resources allocation for maternal and child health care in mountainous areas. Particularly when planning the safe motherhood program should place focus on poor women in mountainous areas.
The human resources should be enhanced in both quantity and quality. Complete equipment should be provided for grassroots health care level in mountainous areas to increase access to health care services for mothers and children. The networks of emergency transport and referral should be improved.
Communication and education for the people on how to provide care before, during and after birth delivery as well as newborn care should be strengthened. People should be mobilized to have ANC, birth attendance by trained health professionals and use safe delivery packages. 

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