M. M a˚lqvist problem invisible. Families and local health staff will not perceive the neonatal period as a time of enhanced risk for the newborn and will not see the need to take the necessary precautions to improve delivery or postnatal care. Under-reporting is not only a matter of withheld interventions and lack of investments but it is also a matter of human rights. According to the UN Conven- tion on the Rights of the Child, to be registered at birth is a right for every child as an acknowledgement of humanhood (50). To be visible in the statistics is to be part of society. Registering neonatal deaths in a systema- tic and honest way will further strengthen the position of all neonates by confirming their value as human beings. The enforcement of human rights is thereby an important part in the effort to improve neonatal survival (51). Ethnic minorities at risk Ethnic minorities in Quang Ninh province are at a higher risk of experiencing neonatal mortality than the majority group of Kinh. This increased risk is independent of the minority mother’s education or the economic status of the household she lives in. Ethnic minorities in Vietnam are known to be marginalised, living in remote and mountainous areas (37, 52, 53). It has also been shown that the ethnic minorities have benefited less from the economic development in recent years than the Kinh group, thus leaving them even more disadvantaged (52, 54). Despite these economic and educational disadvan- tages, there seems to be more to ethnicity that explains the heightened risk of neonatal mortality. The proximate determinants health care utilisation prior to and at delivery seems to be a plausible explanation for the discrepancy in survival between the majority and minor- ity groups since ethnic minority mothers are more likely not to attend ANC and to deliver at home which are well known and in the material presented here as proven risk factors of neonatal death. However, even if the minority mother attends ANC or delivers at a health facility, they are at a higher risk of losing their newborn in the first month. Therefore, a higher home delivery rate and less ANC are parts of the explanation (but do not represent the whole explanation). The remoteness of ethnic minority residences is often brought up as a reason for the disadvantages of minorities. It has, however, been argued that the development of a widening economic gap between the minority and majority is not only attributed to the remoteness of minority settlements but is due to a combination of many social factors (55). Study results support this argument. When analysing the distance from mothers’ homes to the closest health facility, remoteness is still associated with neonatal mortality regardless of ethnic belonging (41). What is demonstrated here is an example of horizontal inequity as described and defined by Stewart (56). Most 8 (page number not for citation purpose) often inequalities in society, whether in politics, economy, or health, are measured from an individual or household perspective. This vertical inequality, measured over a range of individuals or households, omits the group dimension and the existence of inequalities between different culturally defined groups. Ethnicity, which is often defined as having a common history, language, or tradition, may be a joining factor for such a group. Even if there might be large inequalities within the group, the difference between one culturally defined group relative to another may be a powerful preserver of status quo as well as a structural determinant that serves to explain differences in, for example, health outcomes. The uni- versal human need to belong, by identification and affiliation with different groupings, inevitably leads to exclusion as a function to set and keep boundaries. This mechanism can be both internal within the group and external by people and groupings from outside. In this case of neonatal mortality and health care utilisation, the internal forces of ethnicity might cause the preservation of harmful traditions in newborn care. For example, there might be a certain cultural tenet within an ethnic group- ing that forbids certain foods and nutritional intake during pregnancy or there might be complete sets of traditions that relate to childbirth. In Vietnam, the beliefs in traditional medicine are strong (37, 57), which could cause delay in seeking appropriate medical care. External forces of group belonging could, in this context, be any negative attitudes of health staff, discrimination against ethnic minority mothers (since ethnic minority markers might result in different treatment), as well as adverse attitudes in contacts with the health system. This is shown in the findings as an elevated risk for minority mothers even if delivering at a health facility. Finally, there are combinations and interactions of internal and external factors where, for example, the choice of delivery place might be influenced not only by the mother’s perceptions of how she is going to be received at a health facility (internal), but also by her previous experiences of staff attitudes and reception (external). Regardless of what the exact and true mechanisms are which would be within the research field of a social anthropologist the understanding of the concept ‘horizontal inequality’ will anyway be useful when trying to comprehend and explain the adverse health effects of ethnic minority belonging in this setting. Methodological considerations One of the major concerns when gathering data has been to identify all neonatal cases. As was stated, there is a substantial under-reporting of neonatal deaths in official statistics. The reasons for this are many but some of the reasons pose problems, even if a separate data collection system is setup beside the official system. The lack of consistency and coordination of registers at different Citation: Global Health Action 2011, 4: 5724 - DOI: 10.3402/gha.v4i0.5724