M. M a˚lqvist 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% (10). In fact, the definition of skilled attendance at birth involves two components both the presence of skilled health per- sonnel as well as an ‘enabling environment,’ which means adequate supplies and equipment, possibilities for trans- port, and effective communications (10). The recognition of needing to strengthen these parts could also be expressed as understanding the importance of where a delivery takes place (11). Any complications that might arise during delivery, for mother or child, need immediate attention; and the time to intervene is short (9). Being at the right place at the time of delivery therefore consider- ably increases the chances of neonatal and maternal survival (12, 13). Previous results from our research group in Vietnam showed, for example, a strong link between home delivery rate (HDR) and NMR at district level (14). Another important aspect of safe motherhood and delivery is care-seeking. Moreover, the decision to seek appropriate care at the time of delivery, as well as the road to ensuring a safe delivery is an important determinant of neonatal outcome. In a widely cited review article from 1994, Thaddeus and Maine present a conceptual framework of three delays in care-seeking (15). The first delay potentially occurs during the time it takes from onset of a condition requiring medical attention until the decision to seek care is taken. The second delay is the time it takes from once the decision to seek care is made until a health facility is reached. The third delay is the time it takes from arrival at a health facility until appropriate and adequate care is com- menced. Thaddeus and Maine developed their concep- tual framework for obstetric emergencies, but the same mechanisms are valid for preventive care-seeking for delivery, and Gabrysch and Campbell have expanded the framework to involve this aspect as well (16). Vietnam is a country that for many years has shown relative good health statistics in relation to its overall economic status. Through sustained investments in primary health care, Vietnam has achieved great reduc- tions in infant and child mortality rates (17). Officially, the NMR in Vietnam is 12/1,000 2004 (18). However, a study in Bavi district, a health surveillance site west of Hanoi, showed a persistent neonatal mortality rate over the last three decades of the last century (19) exhibiting the same trend as has been shown in many other countries around the world. The Bavi study not only showed a stagnant neonatal mortality, but also indicated that ethnicity was a major risk factor for neonatal death, 2 (page number not for citation purpose) whereas education and economic status was not. Ethnic minorities in Vietnam are living in more remote moun- tainous areas compared to the hegemonic ethnic group (Kinh), and there was a sharp social inequity arising from minority status (20). Aims Neonatal mortality has long been a neglected problem in the world with stagnant development over the past decades. Previous studies within our research group have verified this limited development in Vietnam with persistent neonatal mortality despite major improve- ments in overall under-five survival. The Vietnamese setting is thus offering a model for the exploration of obstacles for improved neonatal survival. Such obstacles can be found in societal structures as well as in patterns of behaviour at an individual level. Stimulating develop- ment requires the acquisition of reliable data as well as a proper understanding of socio-economic and proximate determinants of neonatal death. The overall aim of the thesis was, therefore, to study and assess factors asso- ciated with neonatal mortality with special emphasis on structures within society and the health care system in Quang Ninh Province. Specific aims were to analyse the rate and sources of information on neonatal mortality and to identify and assess socio-economic and proximate determinants of neonatal mortality including care- seeking patterns, place of delivery, and distance to health facilities. Conceptual framework The conceptual framework here presented is adopted from Mosley and Chen, who in 1984 suggested an analytical framework for child health studies (21), which has since been widely used. Mosley and Chen tried to combine sociological and biological explanatory models into a single conceptual framework by sorting indepen- dent variables as either socio-economic (distal) determi- nants 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 analyse distal and proximate factors as being at the same level, which results in a reduction or elimination of the former’s effects (22). The model set up by Mosley and Chen has later been adapted to fit specific areas, for example HIV/ AIDS (23), neonatal health (24), and maternal mortality (25), and the framework here presented is a further adaptation for the analysis of neonatal mortality risk factors (Fig. 1). The socio-economic determinants in the model are ethnicity/culture, religion/conceptions, education/skills, and economy/wealth. The arrows in the model suggest that all the socio-economic determinants are interrelated and affecting each other. For example, is the level of Citation: Global Health Action 2011, 4: 5724 - DOI: 10.3402/gha.v4i0.5724