in 1984 suggested an analytical framework for child health studies [49], which has since been widely used. Mosley and Chen tried to combine sociological and biological explanatory models into a single conceptual framework by sorting independent variables as either socioeconomic (distal) determinants or proximate determinants, creating a hierarchy for analysis. Victora and colleagues further stress this hierarchical approach when they claim that a common mistake in epidemiological literature is to analyze distal and proximate factors as being at the same level, which results in a reduction or elimination of the former’s effects [50]. The model set up by Mosley and Chen has later been adapted to 22 fit specific areas, for example HIV/AIDS [51], neonatal health [52] and maternal mortality [53], and the framework set up in this thesis is a further adaptation for the analysis of neonatal mortality risk factors (Figure 3). Socioeconomic determinants The socioeconomic determinants in the model presented here are ethnicity/culture, religion/conceptions, education/skills and economy/wealth. The arrows in the model suggest that all the socioeconomic determinants are interrelated and affecting each other. For example, is the level of education affecting the amount of income, generating wealth or sustaining poverty, while at the same time a high economic status increases the possibilities for a better education. Even in Vietnam, being a communist country, this is valid, especially with the transformation from planned to market economy and rapid economic development of recent years. The influence of maternal educational level on child health has been explored in many studies. In a seminal paper from studies on maternal mortality in Nigeria in 1979, Caldwell discusses the reason that well educated mothers have better health indicators as being due to their ability to better understand and use the health system, compared to their less educated peers [54]. It would also be reasonable to assume that mothers with higher education are more prone to internalize and adopt new knowledge and behavior, for the benefit of themselves and their offspring. The impact of household economy on neonatal survival could be both direct – through payment capacity directly related to delivery or sickness – and indirect, by the manifestation of better nutritional status. In Vietnam, there are now user fees in the health care system, both official as well as unofficial [55]. However, if a family is poor, it can obtain a certificate from the authorities stating their low economic capacity and thereby assuring them health care free of charge (at least when it comes to official fees). Religion and conceptions about life influence cultural pre-understanding as well as how to relate to wealth and education. Religious beliefs and customs also affect neonatal health and the chances for survival, such as the Vietnamese tradition of not considering a newborn child fully human until it has reached one year of age [47], as described above. Also described above is another factor that could greatly influence the care and survival of newborns: the preference for sons, which is closely related to patrilinearity and patriarchic structures [56], and in the end affects the decision-making power of women. As mentioned above, Vietnam for many years has had a two-child policy, and the desire to breed sons together with an increased spread of ultrasound has, in recent years, led to a sex ratio at birth well above normal variations [37]. 23 Outcome Figure 3. Conceptual framework for factors influencing neonatal mortality, adapted from Mosley and Chen [49]. Ethnicity/Culture Education/Skills Economy/Wealth Religion/Conceptions Temperature control Resuscitation Infection management Survival Mortality Socioeconomic Determinants Proximate Determinants Interventions Delivery factors Place Mode Assistance Complications Neonatal factors Sex Gest. age at birth Birth weight Birth order Health system factors Access Distance Attitudes Awareness Resources Competence Maternal factors Emancipation Nutrition Occupation Age Civic status Birth spacing Household structure Postnatal care Surveillance Nutrition Hygiene Care seeking Exclusive breast feeding Outcome 24 Proximate determinants The proximate determinants in this model are divided into five categories; maternal factors, health system factors, neonatal factors, delivery factors and postnatal care. In most models, there is no hierarchy among the proximate determinants, and it is not strictly in this model either. However, by putting maternal and health system factors above the other groups acknowledges the circumstance that these two have a significant impact not only on the outcome, but also on the three other groups. Characteristics of the mother are of great importance when it comes to birth weight and even the sex of the newborn. The level of female emancipation may decide where the delivery takes place and who is assisting [57, 58]. Further, characteristics of the health system, for example attitudes and availability, greatly influence delivery place [59] and the postnatal care [60, 61]. Notable is that not all arrows between proximate determinants are two-way. The characteristics of postnatal care do not, for example, influence the neonatal factors, whereas the sex of the baby may have a considerable impact on the