REDUCING MATERNAL AND NEWBORN DEATHS in Viet Nam Photo: Theresa Shaver

Presentation Magnitude of maternal and newborn mortality in Viet Nam Human and economic consequences Priority interventions Economic benefits of action

Human Development Index 108 / 176 countries

Socio-Economic Indicators  Per capita income $377  Allocation to health 5%  Access to potable water 52%  School attendance 91%

Total Population78 million Women of reproductive Age 21.2 million Total Fertility Rate 2.25 Characteristics of the Population

Place of Delivery Health Facility 49.6% rural 90% urban Photo: Mary Kroeger

Place of Delivery In certain mountainous and remote areas, over 90% of women deliver at home

Maternal mortality is the death of a woman: while pregnant during delivery or within 42 days after the end of pregnancy WHO, 1992 Year 2000 MMR estimate: 95 / 100,000

Maternal Mortality: Mountainous and Remote Areas 1991 MMR estimate 418 / 100,000

Causes of Maternal Death: Viet Nam Source: MCH/FP, 2000

Emergency Obstetric Care Major causes of maternal mortality cannot be predicted but can be treated through emergency obstetric care (EmOC). (J.Smith, Columbia University, 2001) Accessing these services in a timely manner is key: the “Three Delays” model.

The First Delay Lack of information about danger signs of pregnancy and labor Cultural customs among minorities delay care-seeking Family members, especially men, have an important role to play 53% delay in decision to seek care

 Poor roads  Lack money  No access to transport  Lack awareness about danger signs The Second Delay Photo: Theresa Shaver Delay in referral: 60% Delays in reaching health facilities:

Delay in treatment 63% Wrong treatment 37% Lack equipment11% Lack health staff12% Lack medicine20% (Source: MOH Survey 2000) The Third Delay Delay between arriving and receiving quality care at the health facility:

Nutritional factors contribute to maternal mortality and disabilities

Severe Anemia 47% of maternal deaths in Viet Nam are due to hemorrhage Severe anemia is an underlying factor, making the consequences of hemorrhage more serious Iron and folate help to prevent anemia

Micronutrient deficiencies Vitamin A Thiamin Riboflavin NiacinFolate Manganese Magnesium Iron Iodine Cobalamin CobaltZinc Vitamin C Vitamin E Vitamin D Vitamin K Vitamin B 6 Vitamin B 12 Selenium Chromium Phosphorus

45,000 children will suffer from cretinism 135,000 children will be severely retarded About 1 million children will be mildly to moderately affected Maternal iodine deficiency will lower the IQ of infants and children ( ) Permanent

Maternal Care Newborn Care + Newborn health and survival

Perinatal and neonatal mortality

Infant Mortality: 37 Neonatal Mortality: 18 Source: Viet Nam MCH/FP, 2000 Death in the First Year of Life Viet Nam, 2000

18 Based on State of the World’s Newborns 2001 Stillbirths and late pregnancy losses Perinatal mortality 30 / 1000 total births Perinatal and Neonatal Mortality: Viet Nam, Late neonatal mortality Early neonatal mortality (deaths in first week)

Low Birth Weight Source: WHO, 2001 Congenital anomalies – 10% Other – 5% Prematurity – 24% Birth asphyxia and injuries – 29% Sepsis, tetanus, other infections – 32% Causes of Neonatal Mortality

Death rates vary by weight categories at birth Birth weightIncidenceMortality < 1500 g1 - 3 % % g1 - 8 % % g %5 % 13% of Vietnamese children are born weighing less than 2500 g Global information

Photo: Theresa Shaver

1 infant dies 4 infants suffer long- term impairment Global Newborn Deaths from Asphyxia Source:Sommerfelt,E.

Infection Accounts for approximately 1/3 of neonatal deaths Infections can be prevented by:  TT immunization for pregnant women  use of clean delivery practices & equipment  clean cord care  immediate and exclusive breastfeeding

Families and health workers Early recognition of danger signs Families Knowledge of where to seek care Health workers Prompt and appropriate illness management To avert deaths from neonatal infection:

Timely investments and interventions Photo: Mary Kroeger

Data Team Analysis Newborn and maternal health linkages Estimated benefits of interventions Lives saved Disabilities prevented Economic losses reduced REDUCE/ALIVE: Maternal and Newborn Health and Survival Models

Data Sources Figures on Social Development, 2000 Health statistics yearbook, 2000 MCH/FP report, 2001 UN World Population Prospects, revised 2000 Global Burden of Disease, (WHO) Human Development Report, 2001 Studies from research institutions in Viet Nam

Photo: Theresa Shaver

Maternal Deaths over 10 Year Period No change in level of intervention 12,000 maternal deaths

Maternal Deaths due to Hemorrhage over 10 Year Period No change in management of hemorrhage 5,700 maternal deaths

Economic losses from maternal deaths ( ) The loss of productivity due to all maternal deaths will be about $14,000,000 N VN

Economic losses from maternal deaths due to hemorrhage ( ) The loss of productivity due to maternal deaths caused by hemorrhage will be about $6,500,000 VN VND

Maternal Disabilities

1 maternal death maternal disabilities Maternal Disabilities

Maternal Disabilities ( ) Chronic anemia (including anemia from hemorrhage) Stress incontinence Fistulae Uterine prolapse Emotional depression Maternal exhaustion $660,000,000 from lost productivity

Newborn Deaths and Disabilities

Neonatal Mortality No change in interventions for newborns 300,000 children will die

Newborn Disabilities Mental retardation and cretinism due to IDD Mental retardation due to birth asphyxia and injury LBW can lead to lower IQ and chronic ill health in adulthood

Commitment to Reducing Maternal and Newborn Deaths Viet Nam’s Goal by 2010: To reduce: MMR from 95 to 70 / 100,000 live births IMR from 37 to 25 / 1,000 live births PNMR from 30 to 18 / 1,000 total births LBW from 13% to 6% (Vietnam’s National Strategy on RH Care)

Economic Gains Interventions $198 million saved or gained VND

Moving from Information to Action

Priority Program Interventions To reduce maternal deaths and disabilities from hemorrhage: Iron and folate supplementation Presumptive malaria treatment where appropriate Active management of the third stage of labor Access to EmOC including safe blood transfusion

Every infant needs a skilled attendant who will: ensure clean delivery practices ensure the baby is  dried and wrapped immediately  kept with the mother  breastfed immediately Priority Program Interventions for Newborns Photo: Mary Kroeger

Priority Program Interventions for Newborns appropriate resuscitation for asphyxiated babies early recognition & prompt treatment of sick infants extra attention to low birth weight babies - “Kangaroo Care” iodized salt for mothers in high risk areas

If we act now … $ 198 million in productivity gains 2,000 women’s lives saved 321,000 disabilities averted 52,000 children’s lives saved

Photo: Theresa Shaver

Conditions Needed Strong political commitment to maternal and newborn survival Special focus on the newborn within the framework of existing safe motherhood program Appropriate investment for these interventions Implementation of  functional health information system  clearly defined supervision  monitoring & evaluation mechanisms

Vietnamese women and children have the right to health and life They need quality maternal and newborn care and services Photo: Mary Kroeger

Developed by MOH/Viet Nam, Save the Children/Viet Nam, Saving Newborn Lives, NGO Networks for Health, and Collaborating Organizations with technical assistance from Academy for Educational Development (AED) ALIVE/REDUCE team April 2002

The REDUCE / ALIVE Viet Nam Team 1. Dinh Thuan An MDMCH/FP - MOH 2. Duong Hai Ngoc MDMCH/FP - MOH 3. Nguyen Thi ThangHealth Strategy and Policy Institute, MOH 4. Ha Anh Duc MDCabinet Office, MOH 5. Le Ngoc AnhHanoi Medical University 6. Vo Minh Tuan MD MPHHCMC University of Medicine 7. Huynh Thanh Hai MDTu Du Hospital 8. Bui Thi DiepVietnam Women's Union 9. Le Minh Thi MDSchool of Public Health 10. Nguyen Quang PhuongGeneral Statistics Office 11. Nguyen Ngoc ThangResearch Center for Rural Population and Health 12. Nguyen Thi Phuc MDSC/US 13. Nguyen Thi Huong MDHealth Statistics & Information Division, MOH 14. Nguyen Duc Tien MDDepartment of Treatment, MOH 15. Vu Ngoc Khanh MDMCH/FP, MOH 16. Pham Duc Duc MD MA Institute of Protection for Mothers & Newborn 17. Vu Kim Hoa MDVietnam CPCC 18. Dang Kim Khanh Ly Social Institute 19. Nguyen Bich Van MD Institute of Protection Child Health 20. Nguyen Thi VanPlanning department - MOH 21. Nguyen Hoang YenPath 22. Tran Hoang Nam MD Pathfinder 23.Catharine PownallNGO Networks for Health 24. Judith MooreSC/US 25.Vu Thi Thanh MD MOH 26.Pham Bich Ha MD, MPH SC/US 27.Le Thi Huong MD, MPHHanoi Medical University 28. Dao Xuan Dung MDMedical Practitioner 29.Debbie GachuhiAED 30.Dr. Elisabeth Sommerfelt AED