Background: Neonate’s health is intimately linked to maternal health. Yearly approximately 2.8 million neonatal deaths occur worldwide, counting for more than 40 % of all deaths of children less than five years. Over 70 % of these deaths happen during the first week of life (early neonatal mortality), often the first day, and 99% of these deaths occur in low- and middle-income countries with an often low quality of maternal health care services. Aim: To assess societal and household factors, and maternal health care factors delivered in Rwanda, and how these were associated with early neonatal mortality Methods: Cross-sectional data of interviewed mothers to 7726 children between 2010 to 2014, obtained from the 2014–15 Rwanda Demographic and Health Survey, were analyzed in relation to early neonatal mortality using multiple logistic regression. Results: The factors found to be associated with reduced risk of early neonatal mortality were: delivery at a health facility, delivery assisted by a skilled birth attendant, and no low birth weight neonates. After adjustment with socioeconomic and proximate determinants, the same associations were found with delivery at a health facility and no low birth weight neonates. Conclusions: Delivery at a health facility and not to be born of low birth weight were associated with risk reduction of early neonatal mortality. These findings indicate that interventions to strengthen the antenatal health care system and to increase the utilization of already existing health care services are needed, and to educate practicing professional health care workers about early neonatal mortality.

Background: Prior work examining the association of maternal obesity and neonatal mortality indicate the presence of a positive relationship. However, regional evidence to provide insight on country-level heterogeneities within sub-Saharan Africa (SSA) with nationally representative datasets are non-existent. Objective: We aimed to determine the relationship between maternal obesity and neonatal mortality at the country level in SSA countries. Moreover, we also estimate regional measures of association to complement previous findings. Methods: Demographic and Health Survey (DHS) data from 34 SSA countries conducted from 2006–2016 were used for this study. After missing data (36.9% of cases) were addressed with multiple imputations, we identified a total of 175,860 women for the analysis. Complete case and multiply imputed datasets were analyzed individually with multilevel logistic regression models. Potential confounders adjusted for in the regression model included maternal age, level of educational attainment, area of residence, access to prenatal care, birth order and multiple birth (singleton vs twin birth). Regional and country-specific associations were computed, and unadjusted and adjusted odds ratios (ORs), along with the confidence intervals (CIs) were reported. Findings: Of the total study population, 8,451 (7.6%) were obese. In the regional level analyses, maternal obesity was associated with 40% increased odds of neonatal deaths. This finding was consistent in subgroup analyses by urban and rural residence, and geographic region of residence in SSA. Additionally, obese women were more likely to report neonatal death in the first week of life (OR, days 0–1: 1.39, 95% CI 1.15–1.69; OR, days 2–6: 1.35, 95% CI 1.02–1.79). In the individual country analyses, majority of the countries studied had central estimates supporting elevated odds of neonatal mortality, but the confidence intervals were imprecise. Conclusion: This study highlights the potential burden of neonatal mortality borne by obese women in SSA. There is, however, a need for longitudinal studies to confirm the results.

Child mortality rates do not only reflect the development in a society but also reflect access to basic health interventions and socio-economic conditions. The uneven distribution of child mortality rates is a matter of inequity. Even though there has been a reduction in the child mortality indicator neonatal mortality rate on the global level, the rate is still unacceptably high. Data indicates that it in a few countries, such as Lesotho, the neonatal mortality has an arrested decrease even though being a focus area within the sustainable development goals. This explorative case study aims at finding and explaining the factors behind the arrested decrease in neonatal mortality in Lesotho. Framing this study are the social determinants of health. The results indicate that the combination of HIV and droughts with exacerbated poverty and increased requirements for adequate care as a result, in combination with the vulnerable situation of women has aggravated the situation for new-borns in Lesotho. In order to improve the survival of new-borns in Lesotho measures cannot solely be aimed at improving health care but also have to be directed beyond the direct cause of death such as measures to improve the factors causing poor health. In order to achieve better prerequisites for new-borns measures have to overcome health inequity. It is a fundamental human rights concern.

Despite the unprecedented improvement in child health in last 15 years, burden of stillbirth and neonatal death remain the key challenge in Nepal and the reduction of these deaths will be crucial for reaching the health targets for Sustainable development goal by 2030. The aim of this thesis was to explore the risk factors for stillbirth and neonatal death and change in perinatal outcomes after the introduction of the Helping Babies Breathe Quality Improvement Cycle (HBB QIC) in Nepal. This was a prospective cohort study with a nested case-control design completed in a tertiary hospital in Nepal. Information were collected from the women who had experienced perinatal death and live birth among referent population; a video recording was done in the neonatal resuscitation corner to collect information on the health workers’ performance in neonatal resuscitation.  Lack of antenatal care had the highest association with antepartum stillbirth (aOR 4.2, 95% CI 3.2–5.4), births that had inadequate fetal heart rate monitoring were associated with intrapartum stillbirth (aOR 1.9, CI 95% 1.5–2.4), and babies who were born premature and small-for-gestational-age had the highest risk for neonatal death in the hospital (aOR 16.2, 95% CI 12.3–21.3). Before the introduction of the HBB QIC, health workers displayed poor adherence to the neonatal resuscitation protocol. After the introduction of HBB QIC, the health workers demonstrated improvement in their neonatal resuscitation skills and these were retained until six months after training. Daily bag-and-mask skill checks (RR 5.1 95% CI 1.9–13.5), preparation for birth (RR 2.4, 95% CI 1.0–5.6), self-evaluation checklists (RR 3.8, 95% CI 1.4–9.7) and weekly review and reflection meetings (RR 2.6, 95% 1.0–7.4) helped the health workers to retain their neonatal resuscitation skills. The health workers demonstrated improvement in ventilation of babies within one minute of birth and there was a reduction in intrapartum stillbirth (aOR 0.46, 95% CI 0.32–0.66) and first-day neonatal mortality (aOR 0.51, 95% CI 0.31–0.83).  The study provides information on challenges in reducing stillbirth and neonatal death in low income settings and provides a strategy to improve health workers adherence to neonatal resuscitation to reduce the mortality. The HBB QIC can be implemented in similar clinical settings to improve quality of care and survival in Nepal, but for primary care settings, the QIC need to be evaluated further.

The maternal mortality ratio (MMR) and neonatal mortality rate (NMR) have been persistently high in South Africa, with black, poor, rural women and neonates mostly affected. The MMR and the NMR are indicative of the health of the population and reflect deeper issues such as inequitable distribution of the country’s resources, social exclusion, deprivation, and lack of access to quality public services. The purpose of the study was to develop a model to meet the overall health needs of the socially excluded, the deprived and the vulnerable women by listing those factors that influence maternal and child health outcomes. From the point of view that individual reproduction and health decision-making takes place in a milieu comprising multiple socio-economic and cultural factors, this study attempts to add to the body of knowledge on maternal and child health in order to influence policies and interventions. Data was collected through a multi-staged, qualitative research design. The results show how structural factors result in high risk for poor maternal and child health outcomes, suggesting that the high rates of poor health outcomes are evidence of deprivation of women’s needs due to poverty leading to an inability to cope with pregnancy and childbirth. The results are used to develop a model that proposes pathways for policy action to confront both the structural and intermediary determinants of maternal and child ill health and mortality. These pathways operate through integrative and inter-sectorial mechanisms intended at empowering women and enhancing female reproductive health care activities. / Sociology / D.Litt. et Phil. (Sociology)

O objetivo deste estudo foi construir uma variável para representar a qualidade da assistência ao recém-nascido em estudos populacionais a partir da definição de critérios para as etapas assistenciais visando elaboração de um algoritmo para categorização de condição clínica e identificação de cuidados assistenciais mínimos ou básicos para aquela condição. Realizada revisão da literatura sobre diretrizes para atenção ao recém-nascido foram definidas condições clínicas que se diferenciam pelos procedimentos assistenciais básicos que necessitam receber e foi elaborado um tutorial para a composição da variável assistência ao recém-nascido e que permitisse a aplicação de um algoritmo. Foram criados critérios para definição de quatro etapas assistenciais e verificação da adequação/inadequação em cada uma delas, assim como o peso entre elas para composição da variável síntese. O algoritmo foi aplicado aos dados coletados em prontuários médicos em dois estudos de mortalidade neonatal precoce, um de tipo caso controle e outro uma coorte de recém-nascidos com peso < 1500 g, parte de projeto de pesquisa de mortalidade perinatal, desenvolvido na Região Sul do Município de São Paulo, referente ao período de agosto 2000 a fevereiro 2001. Na primeira etapa assistencial denominada manejo e reanimação na sala de parto encontrou-se para a coorte percentual de adequação para os óbitos e para os sobreviventes acima de 75%. No estudo caso-controle o percentual de adequação ficou próximo a 80% entre os casos e entre os controles foi de 98,7%. Na segunda etapa, denominada berçário utilizado, o percentual de adequação entre os óbitos na coorte foi de 66%. e de 78% para os sobreviventes, sendo que em 17% dos eventos não foi possível obter classificação. No estudo caso-controle, entre os casos o percentual de adequação foi de 67%, o percentual de \"sem classificação\" foi superior a 18% e cerca de 10% dos recém-nascidos morreram na sala de parto. Para os controles o percentual de adequação foi de 97%. Na terceira etapa, denominada procedimentos diagnósticos, o percentual de adequação na coorte atingiu pouco mais de 50% nos óbitos e o percentual de \"não classificados\" foi 26%, e nos sobreviventes a adequação chegou a 73% e os \"sem classificação foi de 20%. No estudo caso-controle, entre os casos , o percentual de adequação foi de 60% e 1 em 4 não puderam ser classificados e nos controles em quase 80% os procedimentos foram adequados e em menos de 15% não foi possível obter classificação. Na quarta etapa, denominada procedimentos terapêuticos, encontrou-se para a coorte percentual de adequação para os óbitos de quase 50% e em mais de 20% deles não foi possível classificar e entre os sobreviventes a adequação foi de 42% e os \"sem classificação\" somaram mais de 20%. No estudo caso-controle, entre os casos o percentual de adequação foi de 49% e os \"sem classificação\" perfizeram 23% e nos controles a adequação foi de 76% e menos de 5% ficou sem classificação. Na coorte o percentual de adequação da variável composta assistência ao recém-nascido foi de 65% para os óbitos e 81% para os sobreviventes e 16% dos eventos não puderam ser classificados. No estudo caso-controle, o percentual de adequação da variável composta entre os casos foi de 70% e 97% para os controles Não foi possível classificar 17% dos casos e 2,2% dos controles. Os resultados encontrados apontam para a viabilidade de aplicação do algoritmo em estudos epidemiológicos e plausibilidade clínica na aplicação e revelaram percentuais menores de adequação para os recém-nascidos mais graves, que têm risco de morrer mais elevado, necessitando de uma assistência diferenciada que procure atuar sobre as condições que levam a esse risco aumentado, exigindo dos serviços de saúde a presença de recursos materiais e humanos mais especializados, nem sempre disponíveis nos serviços. / The objective of this study was to develop a variable to measure the quality of newborn care in population studies, with the definition care phases, in order to develop an algorithm capable of categorizing clinical conditions and corresponding minimal or basic care needs. Literature review identified guidelines for neonatal care and the identification of essential clinical conditions and their basic care needs and a tutorial was developed with the definitions that permitted the application of an algorithm to clinical information registered in hospital records. Criteria for the definition of adequacy of care for 4 phases were created, and their corresponding weight in total adequacy of care. The algorithm was applied to data obtained from medical hospital records in two studies of early neonatal mortality, a case-control and a cohort of newborns weighing < than 1500 g, part of a research project of perinatal mortality, developed in the South Region of the City of São Paulo, with data from august 2000 to February 2001. For the initial phase of care, of management and resuscitation after birth, the proportions of adequacy of care in the cohort was > 75% for both deaths and survivors. In the case-control study the proportion of adequacy of care was near 80% for the cases and 98% for the controls. In the second phase of care, type of neonatal care unit, for the cohort the proportion of adequacy of care was 66% for deaths and 78% for the survivors, and 17% of the events could not be classified. In the case-control study, for the cases the proportion of adequacy was 67%, nearly 10% died before removal from the labor room, and 18% of the events could not be classified. For the controls the proportion of adequacy was 97%. In the third phase of care, called diagnostic procedures, the proportion of adequacy for the cohort was 50% for the deaths, with 26% of the events not classified, and for the survivors adequacy was 73% and no classification was 20%. For the case-control, the proportion of adequacy of cases was 60%, with 1 in 4 of the events not classified, and for controls adequacy was nearly 80% and 15% not classified. In the fourth phase of care, called therapeutic procedures, the proportion of adequacy for the cohort was nearly 50% for the deaths, 20% of the events not classified, and 42% for the survivors, with 20% not classified. For the case-control, in cases adequacy was 49%, not classified 23%, and in controls adequacy was 76%, and less than 5% not classified. For the composite variable adequacy of care, in the cohort, care was classified as adequate for 65% of deaths and 81% of the survivors, and 16% could not be classified. In the case-control, care was classified as adequate for 70% of the cases and 97% of the controls, and 17% and 1% respectively could not be classified. The results indicate that the algorithm is viable for use in epidemiological studies and has clinical plausibility, and revealed lower proportions of adequacy for the sicker newborns, with higher death risk, who need more specialized care, in order to be able to intervene on those conditions that lead to this higher risk, thereby demanding more human and material resources, not always available in these services.

Introdução: Apesar da melhoria dos indicadores da saúde materno infantil, os valores ainda são elevados, com a mortalidade neonatal respondendo pela mortalidade infantil e a mortalidade fetal pela perinatal. Apesar da melhoria da cobertura e qualidade dos dados dos sistemas de informação sobre nascidos vivos e mortalidade, esses não tem informação sobre a morbidade materna e do recém-nascido, disponíveis no Sistema de Informação Hospitalar do SUS e possíveis de serem vinculadas. Objetivo geral: Descrever e analisar o seguimento da gestação, do parto e dos desfechos dos nascimentos das gestantes usuárias do SUS residentes no município de São Paulo no período de 12/08/2011 a 27/01/2013. Objetivos específicos: Obter uma coorte de gestantes SUS com dados secundários. Identificar internações anteriores ao parto por complicações obstétricas, prevalência das gestações de alto risco, tipo de saída após o parto (alta, internação e uso de UTI e óbito materno) e tempo de permanência da internação do parto, no período de 12 de agosto de 2011 a 31 de dezembro de 2012. Caracterizar e estimar a razão de morte fetal e a mortalidade neonatal precoce dos nascidos vivos extraídos da coorte de gestantes SUS no município de São Paulo no período de 01 de junho de 2012 a 27 de janeiro de 2013. Identificar se há diferença da sobrevida dos óbitos neonatais segundo peso ao nascer e uso de UTI neonatal. Identificar potenciais fatores de risco para a mortalidade fetal e neonatal precoce para os nascimentos da coorte de gestante SUS. Metodologia: Tratou-se de um estudo do tipo coorte retrospectiva de população fixa das gestantes cujos nascimentos (nascido vivo e óbito fetal) ocorreram em hospitais da rede SUS no município de São Paulo no período de 01 de junho de 2012 a 31 de dezembro de 2012. Foram investigadas as internações e as readmissões hospitalares das gestantes atendidas nos hospitais SUS ocorridas no período de 12 de agosto de 2011 a dezembro de 2012. Como também, as internações dos recém-nascidos ocorridas no período de 01 de junho de 2012 a 27 de janeiro de 2013. Foram realizadas vinculações pelo método determinístico e probabilístico dos documentos base dos sistemas de informação em saúde (SIS). Foram conduzidas análises de regressão de Cox e regressão logística. Resultados: Foram vinculados 98,3 por cento das declarações de nascidos vivos (DNV) à autorização de internação hospitalar (AIH), 93,8 por cento dos óbitos fetais às AIHs, 93 por cento das AIHs dos recém-nascidos internados ao par anterior e 99,4 por cento dos óbitos neonatais a sequencia de eventos ditas anteriores. 4,3 por cento das gestantes foram internadas prévio ao parto por complicações obstétricas. Maior mortalidade neonatal, razão de morte fetal e internação dos RNs após o nascimento ocorreram em gestantes que internaram por complicações obstétricas. No estudo de sobrevida, houve aumento da sobrevida com o aumento do peso ao nascer. RNs internados em UTIN após o nascimento tiveram menor sobrevida que os RNs não internados. Os fatores de risco para a mortalidade neonatal foram: o número insuficiente de consulta de pré-natal, nascer em hospital de baixo volume de parto, prematuridade, baixo peso ao nascer, APGAR 5º < 7, presença de anomalia congênita e internação após o nascimento. Não realizar consulta de pré-natal, prematuridade extrema (<32 semanas), baixo peso ao nascer (<2499 gramas) e presença de malformação congênita foram fatores de risco comuns aos óbitos fetais e aos neonatais precoces. Raça/cor da mãe não branca e idade materna igual ou superior a 35 anos foram fatores de risco somente para os óbitos fetais. Nascimentos em hospitais com baixo e médio volume de parto foram associados à maior mortalidade neonatal precoce. Conclusão: Gestantes que apresentaram complicações obstétricas tiveram desfechos mais desfavoráveis da gestação, como internação pós-parto e mortalidade materna. Foi identificada também nesse grupo maior readmissão hospitalar dos RNs, maior prevalência de prematuridade e de baixo peso ao nascer, maior mortalidade fetal e neonatal. Internação na gestação e readmissão hospitalar do RN deve ser considerada como eventos sentinelas no monitoramento da assistência ao parto e ao recémnascido na população SUS. A concentração dos óbitos nos primeiros dias de vida refletem as fragilidades na assistência aos recém-nascidos, a gravidade das doenças dos recém-nascidos, as más condições de nascimento e a presença de malformações incompatíveis com a vida. Óbitos fetais e neonatais precoces são influenciados pelas mesmas características proximais dos recém-nascidos. Esforços devem ser direcionados para o aumento da adesão às consultas de pré-natal nas unidades básicas de saúde, com atenção especial para as gestantes não brancas / Introduction: Despite the improvement in maternal and child health indicators, values are still high, with neonatal mortality accounting for infant mortality and perinatal fetal mortality. Despite improved coverage and data quality of information systems on live births and mortality, these do not have information on maternal and newborn morbidity, available in the SUS Hospital Information System and possible to be linked. General objective: Describe and analyze the follow-up of gestation, delivery and outcomes of the births of pregnant women users of SUS residents in the city of São Paulo from August 12, 2011 to January 27, 2013. Specific objectives: Obtain a cohort of SUS pregnant women with secondary data. Identify hospitalizations prior to delivery for obstetric complications, prevalence of high-risk pregnancies, type of delivery after childbirth (discharge, hospitalization and use of ICU and maternal death) and length of hospital stay during the period of August 12, 2011 to December 31, 2012. Characterize and estimate the fetal death rate and early neonatal mortality of live births extracted from the cohort of pregnant women SUS in the city of São Paulo from June 1, 2012 to January 27, 2013. Identify if there is difference in survival of neonatal deaths according to birth weight and neonatal ICU use. Identify potential risk factors for early fetal and neonatal mortality for the births of the SUS pregnant cohort. METHODS: This was a retrospective cohort study of the fixed population of pregnant women whose births (live birth and fetal death) occurred in hospitals of the SUS network in the city of São Paulo from June 1, 2012 to December 31, 2012. The hospitalizations and the hospital readmissions of the pregnant women attended in the SUS hospitals were investigated during the period from August 12, 2011 to December 2012. As well as the hospitalizations of the newborns that occurred in the period from June 1, 2012 to 27 Of January of 2013. Links were made through the deterministic and probabilistic method of the basic documents of the health information systems (SIS). Cox regression and logistic regression analyzes were performed. Results: 98.3 per cent of live birth certificates (DNV) were linked to hospital admission authorization (AIH), 93.8 per cent of fetal deaths to AIHs, 93 per cent of AIHs of newborns hospitalized at the previous pair, and 99, 4 per cent of neonatal deaths in the sequence of events mentioned above. 4.3 per cent of pregnant women were hospitalized prior to delivery due to obstetric complications. Higher neonatal mortality, fetal death rate and hospitalization of newborns after birth occurred in pregnant women hospitalized for obstetric complications. In the survival study, there was an increase in survival with an increase in birth weight. RNs hospitalized at the NICU after birth had lower survival rates than the non-hospitalized NB. The risk factors for neonatal mortality were: insufficient number of prenatal visits, hospital birth with low birth volume, prematurity, low birth weight, APGAR 5 <7, presence of congenital anomaly and hospitalization after birth. Preterm consultation, extreme prematurity (<32 weeks), low birth weight (<2499 grams) and presence of congenital malformation were common risk factors for fetal deaths and early neonatal deaths. Race / color of non-white mother and maternal age equal to or greater than 35 years were risk factors only for fetal deaths. Births in hospitals with low and medium volume of delivery were associated with higher preterm neonatal mortality. Conclusion: Pregnant women who presented obstetric complications had more unfavorable outcomes of pregnancy, such as postpartum hospitalization and maternal mortality. Also in this group, greater readmission of the newborns of the newborns, greater prevalence of prematurity and of low birth weight, greater fetal and neonatal mortality were also identified. Nursing admission and hospital readmission of the newborn should be considered as sentinel events in the monitoring of delivery care and the newborn in the SUS population. The concentration of deaths in the first days of life reflects weaknesses in the care of newborns, the severity of newborn diseases, poor birth conditions and the presence of malformations incompatible with life. Early fetal and neonatal deaths are influenced by the same proximal characteristics of newborns. Efforts should be directed towards increasing adherence to prenatal consultations in basic health units, with special attention to non-white women. Key Words: Linkage, hospital admissions for obstetric complications, neonatal mortality, fetal mortality

The incidence and mortality rates of neonatal tetanus (NNT) remain underreported in Nigeria. This cross-sectional study was guided by the Mosley and Chen's model for the elements of child survival in developing countries. The goals of the study were twofold: (a) to compare the NNT prevalence and the mortality rates from the existing surveillance system and active surveillance of health facility records in 7 selected health facilities from 2010 to 2014 in Katsina state, Nigeria and (b) to assess the associations between selected NNT risk factors, number of maternal tetanus toxoid injections, frequency of antenatal visits, place of delivery, and cord care, and neonatal mortality as the outcome variable. Data from 332 NNT records were extracted through retrospective records review and analyzed using a logistic regression model. The prevalence of NNT and mortality rate were 336 cases and 3.4 deaths per 100,000 population, respectively, while the prevalence of NNT and mortality rate reported through the IDSR system were 111 cases and 1.0 death per 100,000 population, respectively. Only neonates whose mothers had 1 dose of tetanus toxoid vaccine were significantly associated with NNT mortality, (p < 0.05), OR = 4.12, 95% CI [1.04, 16.29]. Frequency of antenatal visits, place of delivery, and cord care were all not significant predictors of NNT mortality. Implications for positive social change include gaining knowledge on associations between NNT risk factors and neonatal mortality, and strengthening the NNT surveillance system with the capacity for early detection of potential risk factors to develop specific public health interventions aimed at improving the outcome of neonatal tetanus.

The dissertation deals with the infant mortality decline in Iceland during the 19th and early 20th Century. It shows that despite its low degree of urbanization, pre-transitional Iceland displayed higher infant mortality rates than most other European countries. Levels are only comparable with a few areas in Europe, all of whom were known for a tradition of artificial feeding of newborns. In the Icelandic case, infants were either not breastfed at all or were weaned at a very young age. Another characteristic of infant mortality in Iceland were huge fluctuations during epidemics. Because of the isolation of the country, several diseases that had become endemie in other societies, such as measles, became dangerous epidemics in Iceland and affected all age groups. After 1850 the effects of epidemics declined and 20 years later there was a steep decline in infant mortality. By the beginning of the 20th Century infant mortality in Iceland was lower than in most other societies. Although epidemics often had important temporary consequences upon infant mortality level in pretransitional Iceland, being breastfed or not was without doubt the most important determinant of infant survival. There were huge differences in infant mortality levels between areas where breastfeeding was common and those where newborns were artificially fed. Towards the turn of the 20th Century significant changes occurred. Even though there were still differences in infant mortality between those babies who were breastfed and those who were not, infant survival had improved greatly and survival chances of Icelandic newborns that were fed artificially became in an international perspective relatively good. Midwives played a central role in the infant mortality decline in Iceland. Growing secularization during the second part of the 19th Century improved educational opportunities for women and also changed the content of education. Improved educational opportunities were reflected in changes in the education of midwives. At the same time there was growth in the publication of books that directly dealt with the issue of infant health. The increase in the number of educated midwives was a factor of central importance. The interaction between midwives and a literate population was most likely the key to infant survival in the Nordic countries. This study shows that that the custom to breastfeed spread earlier in areas with higher literacy. Not only is it plausible that the interest in changing prevailing traditions was directly related to literaey levels of individuai mothers, it is also shown that midwives had the best education in areas where literacy rates were high. On the other hand, the remarkable improvements in infant survival obtained towards the end of the 19th Century were scarcely linked to changes in the economic structure. Those factors only started to play an important role in the 20th Century. In its initial stages, changes in infant feeding and improvements in personal hygiene were more important / digitalisering@umu

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.