of the country where Chinese culture is more predominant. According to the teachings and traditions of Confucius, it is the son of the family who will get the inheritance and preserve the family line into the future. It is also 20 the son who is allowed to sacrifice for the ancestors and looks after their graves [36]. Thereby, a son has the responsibility to look after the well-being of deceased relatives, and failing to have a son is considered disrespectful to the ancestors. This strong preference for sons, for cultural, economic and social reasons, has been one of the driving forces of an increasing sex ratio at birth (SRB) in recent years [37]. A two-child policy was formally introduced by the authorities in Vietnam in 1988 in order to lower fertility rates [38]. This policy was successful in the sense that the fertility rate decreased from 3.8 to 2.3 during the period 1989-1999 [39]. In the beginning of the new millennium the policy shifted to a “small-family size” norm. After a couple of years, the fertility rates started to increase and a reinforcement of the one-to-two-child policy was issued in 2005. The efforts by the authorities to keep fertility rates low, together with an increasing spread of ultrasound technique in a society with strong son preference, has lead to an increasing SRB. Since 2004, the SRB has increased by 1 every year, reaching 112 in 2008 [40]. Ultrasound and abortion are free in Vietnam, but sex determination and selective abortions are illegal according to a decree issued by the Vietnamese authorities [41]. This document does not, however, state how the regulation should be enforced, and there is a widespread overuse of the ultrasound technique with reports of 6.6 ultrasound scans on average among pregnant women in Hanoi [42]. Son preference and an increasing SRB have implications for the neonatal period, as well. Studies have shown excess female child mortality in cultures with son preference, such as China and South Korea [43, 44]. This increased risk of child mortality for girls is usually explained in terms of discrimination against girls, socioeconomically, as well as through healthrelated behavioral factors [44]. Care-seeking patterns are different for girls, and home deliveries are more common if the mother is expecting a girl. A study from China showed that two-thirds of the excess female deaths took place within the first 24 hours after delivery, displaying the importance of delivery place as well as the possible neglect of female newborns [44]. Stories of neglect and even infanticide are not uncommon in this region even if it is a difficult thing to verify statistically. Concepts of the neonatal period Beliefs and how we look upon the world greatly influence our behavior, and the neonatal period is no exception. In the Vietnamese setting Confucianism, Buddhism and Taoism coexist in what is called the “triple religions” (tầm giao). Confucianism handles morality and social interaction, as exemplified above with a strong preference for sons in the society. Taoism deals with the interpersonal relationships as well as the changes and fluxes of nature. Buddhism, in turn, renders an explanatory model for life and the afterlife, 21 and Buddhist rituals at birth and death are important parts of Vietnamese life [45]. When a child is born there is an expected “isolation time” for the newborn and mother, lasting 7 days for boys and 9 days for girls [46]. No visitors are allowed into the family’s home during this period, which is in contrast to official guidelines for newborn health care stating that home visits by a midwife should take place during the first week after delivery. Even if most midwifes report home visits according to the guidelines, these are very seldom performed since home visits are in opposition to traditions and customs that advocates such a period of isolation for the mother and newborn after delivery. After this period, which often is extended to one full month, a “Thanksgiving for the Midwives” is observed (Lễ Cúng Mụ) with sacrifices to the 12 divine midwives [46]. The next ritual of importance is the “Rite of the First Full Month” (Lễ Đầy Tháng), where the newborn is named and officially celebrated together with friends and relatives [46]. After this ritual, which coincides with the end of the neonatal period, the isolation is completely over. After one year, the “Rite of One Full Year of Age” (Lễ Đầy Tuổi Tôi) is held. This celebration is an expression of gratitude towards the ancestors and it marks the humanhood of the child. Not until this time is the child regarded officially as a “human being” (con người). Thus, if a child dies before reaching one year of age it will not be considered to possess a soul and instead of becoming a ghost (ma), it would become a “little demon” (ranh). This “little demon” is believed to be able to reincarnate, which would mean a lot of misfortune and problems to the family unless handled in a correct ritualistic way [46]. This concept of a newborn not being fully human may affect the way newborns are treated and perceived, and has implications for the health care system: in practice, but also for the reporting system and for the practical implementations of neonatal care policies [47]. Determinants of neonatal mortality All good research rests upon a theoretical foundation, and the conceptual framework for this thesis is adopted from Mosley and Chen, who were inspired by Davis and Blake [48] and