health facilities made it difficult to compare cases. Additionally, in Vietnam, there is a widespread attitude about the importance of showing good statistics, locally referred to as the ‘achievement disease.’ This also offers a strong force within the Communist and Confucian systems, where it is not allowed to criticise superiors and where goals are expected to be met. Many of the neonatal deaths occurring are due to poor competence and mishandling of health staff and instead of requesting more training and resources the problem is hidden in order to avoid disgrace. Such ‘achievement disease’ is sometimes so institutionalised that community health staff can be given directives from higher levels to tamper the reports. To deal with this issue, a case-referent study design was applied in order to get all information directly from the mothers since the official registers could not be trusted. However, the problem with identifying neonatal deaths remained and only through the use of a number of different sources (village health workers, admission registers, birth registers, mortality records, etc.) could an acceptable level of completeness be reached. When registering a perinatal health event, one of the problems is that of defining a neonatal death. Since such a large proportion of neonatal deaths occur intrapartum, it might sometimes be difficult to distinguish between a neonatal death and a stillbirth (13), and many early neonatal deaths are misclassified as stillbirths (58). It has also been shown that neonatal deaths occurring in the first hours after birth or in small babies are less likely than other neonatal deaths to be reported (28, 59, 60). A neonate must, by definition, be alive after birth before dying to be classified as a neonatal death event even if life is just for a very short time. If the birth assistant is not receptive at the time of delivery, deciding whether or not the baby was a live birth or a stillbirth can be difficult. Conclusion: who can save the unseen? The neonatal period has long been neglected in global health, resulting in a persistent neonatal mortality despite considerable improvements of overall child survival in the recent decades (61). Fatalism and misconceptions have stalled development, and the width of the problem has not been visible in international statistics. The findings from Quang Ninh province reveal the invisibility of neonatal mortality in official statistics. Reasons for this under-reporting are diverse, but a common trait is the low importance the issue receives at all levels: families are told to forget and go on with their lives and that it is unavoidable that newborns die and health staff members are afraid to be accused of maltreatment or poor achievement and therefore omit reporting neonatal deaths. The consequences of this under-reporting are severe, ranging from lack of investments at the global level to neglect of the issue all the way down to the individual level. Citation: Global Health Action 2011, 4: 5724 - DOI: 10.3402/gha.v4i0.5724 An invisible and marginalised trauma It is not only in the registers and statistics that neonatal mortality is invisible. It is also a matter of marginalisation and hierarchical structures. In a patriarchal society where sons are regarded higher than daughters, women’s health is not a priority. Childbirth and the postnatal period fall into the category of gender inequity, resulting in an association between the social position of women in society and child health and survival (62). In the same way, the poor, the less well educated, and the ethnic minorities are discriminated against and marginalised with inequities in health as the result. The Vietnamese government has put considerable emphasis on reducing economic disparities over the years and has seemingly managed well. However, at the time of data collection, there remained a large inequity based on ethnicity that is reflected in the material presented in this thesis. The causes of such inequity are complex involving higher home delivery rates and less ANC attendance among ethnic minorities. Many home deliveries are unknown to health care officials, and skilled attendance at birth can therefore not be promoted or provided. But the sources of ethnic inequity can also be found among the attitudes and level of discrimination within the health system causing difficulties in communication and a reluctance to seek care. In a rapidly changing society like Vietnam, a steep economic development causes the gaps between different segments to widen. Therefore, it is even more important to identify and acknowledge groups at highest risk here found to be ethnic minorities and to target them with interventions for improved neonatal survival. Conflict of interest and funding The author has no conflict of interest. The project has been financially supported by Sida/SAREC. References 1. Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG, et al. Global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet 2010; 375: 1969 87. 2. Lawn JE, Kerber K, Enweronu-Laryea C, Massee Bateman O. Newborn survival in low resource settings are we delivering? BJOG 2009; 116: 49 59. 3. Ahmad OB, Lopez AD, Inoue M. The decline in child mortality: a reappraisal. Bull World Health Organ 2000; 78: 1175 91. 4. Martines J, Paul VK, Bhutta ZA, Koblinsky M, Soucat A, Walker N, et al. Neonatal survival: a call for action. Lancet 2005; 365: 1189 97. 5. Lawn JE, Cousens SN, Darmstadt GL, Bhutta ZA, Martines J, Paul V, et al. 1 year after the lancet neonatal survival series was the call for action heard? Lancet 2006; 367: 1541 7. 6. Rajaratnam JK, Marcus JR, Flaxman AD, Wang H, Levin- Rector A, Dwyer L, et al. Neonatal, postneonatal, child- hood, and under-5 mortality for 187 countries, 1970 2010: a systematic analysis of progress towards Millennium Develop- ment Goal 4. Lancet 2010; 375: 1988 2008. 9 (page number not for citation purpose)