Báo cáo nghiên cứu khoa học: "Bằng chứng về hiệu quả của các can thiệp trong chăm sóc trẻ sơ sinh: có đơn vị chăm sóc sơ sinh huyện giải quyết các vấn đề về sức khỏe trẻ sơ sinh trong Như Thành và các bệnh viện Ngọc Lặc, tỉnh Thanh Hóa, Việt Nam?" potx

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153
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:

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.



154
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


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

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 km
2
. 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.


157

Inputs
Provision of
equipment for ENBC
in CHCs and district
hospitals
Communications,
Advocacy, Partnerships
Operations Research to inform Scale-up
Set-up referral
system
Establish Newborn
Care Unit at DH
IEC materials
availability at health
facilities…
Refresher training on
ENBC for Pediatric
Dept. of DHs
Refresher training on
ENBC for midwives/
nurses at CHC, DHs
Training courses on
counseling,
supportive

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

: Improved newborn health
and survival in Viet Nam
SO
: Improved use of key practices and
services that protect and promote the health of
newborns

Intermediate
Result 1
Increased access to
and availability of
key services,
equipment, and
supplies for
newborn health


Intermediate
Result 2
Increased quality of
essential
care and
complication
management for
newborns


Intermediate
Result 3
Increased

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

Obstetri
cs Dept,
DH


Prov Project Management
Board
(
Provincial Health Department
)

NBC
Unit of

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

Prov Project Management Board
(Provincial Health Department)
Province District Commune

Village

Central

INFORMATION FLOW AND DATA BASE SYSTEM

VHW
Legend: Reporting to

Supervision and giving feedback


159
3.2. Preliminary results
The project was supposed to begin in January 2007 and finish in October, 2011.
However, due to a delay in administrative procedure clearance with the local authorities
and preparation for human resources (developing training manual and training of health
workers at provincial, district and communal level) and purchase of essential equipment
for district newborn care unit, actual service delivery began in June, 2008.
The performance of district newborn care unit has actually improved health
outcomes of newborns in the 2 intervention districts thanks to increased access to and
availability of newborn care services. Two respective newborn care units in 2 district
hospitals were established using the recommended standards in the National guideline
for newborn care at different levels i.e. room space, infection control, a list of essential

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

160
staff of the newborn care unit while the mother was cared by obstetric staff. If the
complications became serious, the baby would be transferred to the well-equipped
newborn care unit for treatment and follow-up.
In addition, other supporting communications materials, e.g., brochures,
booklets and posters of maternal and newborn care were provided to the district
newborn care unit and obstetric department of the hospital. These materials will
facilitate the hospital health workers to counsel and advice their patients or care takers
about how to promote exclusive breastfeeding, how to recognize danger signs in infants,
and what actions should be taken in particular clinical situations.
There was a huge difference in neonatal death, referral rate and home delivery
between pre-and-post intervention periods (Table 3).
Table 3. Key indicators in newborn health status in Ngoc Lac and Nhu Thanh
No Key indicators
Pre-intervention
(2006)
Preliminary results
(2008-2009)
1
Neonatal death
- Ngoc Lac
- Nhu Thanh

19.4‰
21.9 ‰

14.4‰
8.5 ‰
2
Referral rate

- 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,

and 21.9%o (2006) to 8.5%o (2009) in Nhu Thanh. The referral rate of newborn
complications and home delivery also declined sharply in both districts.
The presence and operation of the district newborn care unit has brought about
not only medical benefits but also non-medical benefits for local community, health care
givers and managers. The district newborn care unit has helped fill the gap in the current
health care delivery system. This observation is reflected in following aspects obtained
from expert opinions:



161
Benefits for the health care provider
 Increase opportunities of investments in neonatal care and treatment
 Increase revenue for hospital from provision of newborn care services
 Improve professional skills in newborn care for health workers
 Regain the public’s confidence in district health workers for treating
difficult cases
 Take advantage of available human resources (took only 3 months for
training)
 Avoid wasting human resources as there was no need to recruit new staff
Benefits for the health sector
 Bridge linkages between the grassroots and higher levels in treatment of
neonatal complications
 Reduce patient load of common neonatal diseases in provincial and
national hospital. Other districts in the vicinity also benefit from the
functioning newborn care unit.
 Help provide technical support for lower levels more efficiently because
the district hospital is able (personnel, infrastructure and equipment) to
provide
 Newborn care services are available for lower level.

 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

delivery. The family then quickly transferred her to Như
Thanh district hospital, one of two district hospitals in Thanh Hoa province with a specialized Newborn
Care (NBC) unit. At about 11 PM that same night, she prematurely gave birth to two twin boys, Bùi Anh
Tuấn, weighing 1,600 grams and Bùi Anh Tú, weighing 1,400 grams. Both boys were premature by
several weeks and therefore had low birth weights.
The doctors from the Obstetrics and Pediatric departments provided a detailed consultation
and referred the twins to the NBC unit. Here, the doctors diagnosed them with pneumonia, and classified
them as pre-term and with low birth weight; therefore they were prescribed with anti-biotic treatment for
5 days, and placed in the neonatal warmer to stabilize their body temperature. During this time, the
doctors encouraged their mother to breastfeed them whenever it was appropriate. Breast milk is the
ideal source of nutrition for infants in the first six months of life, and the NBC unit doctors promote and
educate mothers about providing immediate and exclusive breastfeeding for newborns.
When their conditions were stabilized, NBC unit nurses guided the mother and grandmother-in-
law to warm the babies with the Kangaroo method (Though they called it Kamaru!). The Kangaroo
method of care (KMC) refers to using skin-to-skin contact as the principal means of warmth, rather than
relying completely on an incubator machine.
Many family members, grandfather, grandmother, and mother, took turns warming the twin
boys, Tuan and Tu. The two boys stayed in the NBC unit for 10 days, and then the family requested to
return home because of costs (food, travel, etc.). Once they reached home, the two boys were warmed by
KMC, day and night, for another month. They were visited by the NBC Unit staff. The family also
contacted the NBC unit staff to seek medical advice when they needed it. When they were 4 months old,
they appeared very cute and healthy. Both boys were exclusively breastfed for the first 3 months after
they were born. Thương looks very happy when talking about her babies: “We thank doctors and
nurses of the hospital very much because my boys were warmed by warmer there. Without it, we would
have had to transfer our babies to Thanh Hoa.”



163
4. Discussion

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

services, both directors of district hospital reported that revenue from newborn care
service provision was over 90% increased over the pre-intervention period, regardless of
source of revenue. This was understandable because previously almost all newborns
with complications were transferred to higher level, thus no service costs for newborn
care incurred.



164
Limitations of the report
This report has some limitations. Although the project has a comprehensive
intervention package of newborn care covering facility-based and community-based
intervention, this report merely touched on facility intervention while its impact might
have come from community interventions, i.e., reduced home birth thanks to education
and communication activities. There is no detailed analysis of newborn complications
by disease category, and correlation between complications and place of delivery, socio-
economic status of the family, and other health determinants. This is an ongoing and
longitudinal study, thus these preliminary results may not help come to confirmed
conclusion of effective district newborn care unit. An intervention-control design could
also help to conclude effective district newborn care unit and positive newborn health
outcomes but the evaluation should be delayed until end of the project.
5. Conclusions
The decision of locating a district newborn care unit in a pediatric department
was rational as it facilitated a smooth workflow in the care and treatment for newborns
within the district hospital setting. Neonatal deaths in Ngoc Lac and Nhu Thanh districts
of Thanh Hoa province can be averted with low cost intervention through the
establishment of district newborn care unit. The birth of the district newborn care unit
has aimed at three targets: improved health care delivery system (reducing workload for
higher level when they have to treat unnecessary cases referred from lower level);
improved quality of care (doctors and nurses are confident in providing care for patients

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)