postnatal care. Maternal factors are not easily affected by the other groups, but of course have a major influence on the choice of delivery place and the quality of postnatal care. Interventions In the end, the difference between death and survival in the neonatal period is dependent upon what responses are given to the newborn’s needs and to the threats to the neonate’s health. Most of the interventions needed to save newborn lives are not complicated, costly or high-tech, but instead simple and straightforward with a potential of reducing mortality with up to twothirds [16]. With the addition of resources and the latest medical technology, it is possible to save almost all newborns, as statistics from Singapore exhibit, further emphasizing the importance of actions taken or not taken [62]. By adding the level of interventions in the model, we would like to express that there is nothing definite or unavoidable with neonatal deaths. The interventions in the model are examples based on priorities made by WHO. Delivery care utilization In order for interventions that improve the chances for neonatal survival to be put into practice, demand and supply need to meet: there should be enough resources and knowledge among care providers, as well as adequate care-seeking behaviors and a readiness and willingness to utilize the existing 25 health system among families. Therefore, one proximate determinant that has been investigated in this thesis is how mothers utilize delivery care. Skilled attendance at birth One of the most important factors to ensure neonatal survival (as well as a reduction in maternal mortality) is the presence of skilled attendance at birth [63, 64]. To be skilled, however, is not the same as being trained, and in a joint statement from WHO, UNFPA, UNICEF and the World Bank, the definition of skilled attendance is ‘‘exclusively referring to people with midwifery skills (for example midwives, doctors and nurses) who have been trained to proficiency in the skills necessary to manage normal deliveries and diagnose, manage or refer obstetric complications. They must be able to manage normal labour and delivery, recognise the onset of complications, perform interventions, start treatment and supervise the referral of mother and baby for interventions beyond their competence or not possible in the particular setting’’ [64]. To have skilled attendance at birth might avert a large proportion of all intrapartum-related neonatal deaths if good coverage is reached [16, 65]. A person with knowledge about and experience of difficult situations and potential delivery complications is taken for granted (and is almost expected as the ‘norm’) in most high-income countries. Yet, in many places of the world this is not the norm, and globally 65.7 % of all pregnant women deliver without a skilled attendant (2008 estimate). In Asia, the skilled attendance rate is as low as 46.5 % [66]. According to global calculations by WHO, there are about 330 000 midwives missing to fill the need [67]. For this gap to be filled there needs to be a serious commitment made by government and health care planners. In attempts to speed up the process of safer deliveries, numerous trials to train Traditional Birth Attendants (TBA) have been performed, with the notion that TBAs would be more available and accessible within a community. Evidence for the effectiveness of TBAs in reducing maternal and neonatal mortality is, however, still controversial and much of their ineffectiveness depends on their lack of integration with existing health systems as well as the absence of emergency back-up systems [68]. The efforts with community-based strategies must therefore be combined with health system strengthening strategies in order to have a chance to succeed [63, 68]. The place of birth In fact, the definition of skilled attendance at birth involves two components – both the presence of skilled health personnel as well as an “enabling environment”, which means adequate supplies and equipment, possibilities 26 for transport and effective communications [66]. The recognition of needing to strengthen these parts could also be expressed as understanding the importance of where a delivery takes place [69]. Any complications that might arise during delivery, for mother or child, need immediate attention; and the time to intervene is short [65]. Being at the right place at the time of delivery therefore considerably increases the chances of neonatal and maternal survival [70, 71]. Results from the NeoKIP baseline in Vietnam showed, for example, a strong link between home delivery rate (HDR) and NMR at district level (Figure 4) [72]. Neonates born at home are often delivered without skilled attendance and are at a higher risk of intrapartum-related death and morbidity [68]. Even if deliveries with skilled attendants could be performed either at home or at a health facility, it has been argued that the most effective strategy for lowincome settings would be to have deliveries with skilled attendance at a health center with at least a good referral capacity in case of emergency [73]. In reality, skilled attendance in most places therefore becomes synonymous with facility delivery. Even if a delivery takes place at a health facility, 0,0 10,0 20,0 30,0 40,0 50,0 60,0 Proportion home deliveries (%) 50,0 40,0 30,0 20,0 10,0 Neonatal mortality rate Figure 4. Percentage of home