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4
Background: Hospital care for sick neonates is increasingly available in many developing countries; however, availability of neonatal services may not improve access to life-saving medical therapies due to a variety of financial, religious, infrastructural, or social reasons.
Objective : To characterize barriers to neonatal care that might be amenable to change as a first step in improving newborn outcomes in developing countries.
Methods : Face-to-face half-hour interviews of parents whose infant was hospitalized within the first month of life in hospitals in Vietnam and Cambodia . Trained interpreters conducted interviews in the parents’ primary language.
Results: To date, 89 parents have been interviewed
(mother’s mean age 27 yrs, mean education 7.5 years).
Only 20% lived in cities; 22% had delivered an infant at home, 55% in a hospital. 5% of parents had had a prior child die in the first month of life. While 83% rated their infant’s health as good or excellent, 73% reported difficulty in caring for their infant. Most
(67%) parents felt that newborn care was accessible, but 26% did not know where to obtain care.
Approximately 50% felt that hospitals were too far from home and 55% rated newborn care as too costly.
Medical or environmental factors were cited as causes of neonatal illness by >75% of parents. Of 20-25% that cited spirits, curses, or karma as causing illness, only 15% believed that providers could circumvent resulting diseases. Overall, 49% reported prior newborn care as unsatisfactory, citing cost (55%), infant outcome (54%), poor communication (53%), hospital cleanliness (50%), availability of medications or services (51% and 38%, respectively), and staff availability or demeanor (47& and 46%, respectively) as significant barriers to obtaining health care for infants.
Conclusions : Simple improvements in hospital hygiene, staff demeanor, and communication with parents may diminish some barriers to neonatal care.
Serious infrastructural problems such as hospital crowding, financial constraints, limited hours of service and distance to health care sites pose more difficult barriers to improving access to medical care for sick newborns in the developing world.
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Capacity for neonatal care is improving in many developing countries, and outcome statistics in some areas compare to US and European outcomes.
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However, neonatal care may not easily accessed in countries where barriers limit access to heath care for sick newborns.
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The effects of local economic, religious, infrastructural, and social barriers as obstacles that impede access to care are poorly understood.
– To characterize barriers experienced by parents seeking neonatal care for their sick newborns in the first month of life.
– To identify barriers amenable to economicallyfeasible and culturally-appropriate interventions to improve regional health care for sick newborns.
– To inform the development of local methods to improve health care delivery to newborns .
100
80
Demographic characteristics
Age of mother, yrs
Education, yrs
Residence: city village
22%
61%
Livebirths, n
Delivered at hospital
Choice of delivery site?
Skilled attendant @ delivery?
Death of a baby in 1st month of life?
Hanoi,
Vietnam
(n=48)
25.9
10.3
1.4
62%
85%
88%
5%
Siem Reap,
Cambodia
(n=41)
Parent perception of child’s health status
100
80
28.6
4.4
18%
70%
2.5
46%
81%
85%
18%
60 60
40 40
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Interview instrument :
38 questions covering-barriers to accessing newborn care assessment of infant’s health status attitudes on treatment of sick newborns prior experience of newborn health care demographics
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Pre-implementation :
Translation  Vietnamese and Khmai
Interpreters experienced in newborn care trained to use interview tool
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Interview : structured, face-to-face, ½-hour interview in parent’s primary language
20
0
 Sample : parent of newborn hospitalized at birth or within the 1st month after birth.
Inclusion criteria:
Newborn in-patient OR discharged infant aged <6 months from participating hospital
Exclusion criteria:
Refusal to participate (nil)
Hanoi Siem Reap
Health status = poor/very poor pollution
GI problems too young
20
0
Hanoi Siem Reap
Ease of care = difficult/very difficult
Parents’ beliefs on causation of illness not enough food too small
Acknowledgements
 Supported by the University of California
Pacific Rim Research Program, and Friends
Without a Border. With special thanks to the
Department of Pediatrics, SFGH breathing problems too cold fever karma spirits/curses
0 20 40 60 80
Siem Reap
Hanoi
100
Economic barriers
Pay all costs of child’s medical care
“Easy to pay for hospitalization”
Days could stay away from home/work
No limit to stay
“Care should be given even if parents cannot pay.”
Hanoi,
Vietnam
54%
23%
9 d
0/47
100%
Siem Reap,
Cambodia
58%
12%
13 d
20/41
93%
Parents’ beliefs about health care delivery
Punish providers who are unable to rescue a sick infant after birth
Punish providers who fail to provide necessary treatment for sick newborn
Providers can prevent spirits/god/magic from making a baby sick or die
Life or death depends on parents' ability to care for infant
0 20 40 60
Siem Reap
Hanoi
80 100
Health care priorities by age group
< 1 yr
1-10 yr adolescent adult elder all the same
Problems with newborn health care in region
Prior hospital care not good
Do not know where to get hopspital care
Hospital is too far away
Newborn care costs too much
Newborn care is difficult to access
0 20 40 60
Problems with hospital care in past
Siem Reap
Hanoi
80 100
Outcomes
Staff demeanor
Available medications
Available services
Cleanliness
Privacy
Costs of newborn care
Waiting time
Siem Reap
Hanoi
0 20 40 60 80 100
 Small sample with significant case mix
 Hospital-based study may not reflect barriers to health care in surrounding areas
 Use of medical staff from participating hospitals may have biased parents’ responses
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Parents perceive their infant as healthy, but cite difficulty in caring for them in more economically disadvantaged developing countries
 Belief in non-medical causes of illness does not act as a barrier to care.
 Local economic constraints act as important barriers to newborn care.
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Health care is perceived as a right, with infants the highest priority preferentially; the concept of social justice is less widely reported.
 Data on prior problems with newborn care in hospitals and in the surrounding region can inform quality improvement efforts in hospitals in these developing countries