LOW BIRTH WEIGHTS IN VIETNAM

Guidelines for low birth weight: a literature review comparing national guidelines in Vietnam with WHO guidelines

Review article

Line M Pederson

 

Background

This study was prompted by the persisting high prevalence of low birth weight (LBW) in Vietnam. LBW, defined as an infant weighing less than 2500g, is a leading cause of perinatal (22 weeks of gestation to 7 days postpartum) and neonatal (within 28 days postpartum) deaths globally. It contributes indirectly, through maternal factors, and directly, through postpartum factors, to 40-60% of newborn mortality.[1] LBW is the most important criteria for determining both immediate and long-term outcomes of neonates and infants. This includes chance of survival, healthy growth and freedom from morbidities.[2]

Vietnam is part of the WHO Western Pacific Region (WPR). Neonatal deaths in the WPR region contribute to the highest proportion (56%) of the under-five mortality compared to other WHO regions.[3] In Vietnam specifically, neonatal deaths account for 55% of the under-five mortality.[4]

Nutrition has a major impact on LBW and associated infant morbidity and mortality.[5-7] Nutritional factors are related to the biological processes that affect the fetus in utero and the mother’s physiology.[8, 9] The most important maternal risk factors[10] increasing risk of LBW are: body mass index (BMI) at conception[7, 8, 11-16], stature[17, 18], nutrition (including suboptimal gestational weight gain[10, 11, 19]), intake of micronutrients (iron[20, 21] and iodine deficiency[22]), maternal age (age <18[23-27], age >35[28, 29]) and cultural food habits and behaviours.[30, 31]

Maternal pre-partum health status, immediate care of the LBW infant and exclusive breastfeeding (EBF) for 6 months are crucial to reducing the burden of LBW.[32] Guidelines are important as they act as a tool for quality assurance, facilitating improved quality of care provided by informed healthcare workers.[33]

Methods

A Quick Scoping Review was performed to evaluate existing knowledge of LBW. This involved a rapid review of literature on LBW risk factors. Guidelines were obtained from the WHO website, Vietnamese government website, online and through formal email correspondence with the WHO WPR Reproductive, Maternal, Newborn, Child and Adolescent Health team to ensure the most recent guidelines were included.

An extensive literature search was then conducted to identify barriers to proper implementation of LBW guidelines in Vietnam. Bibliographic databases (Pubmed, ProQuest, Cochrane Library, Google Scholar, WHO and UNICEF) were searched using combinations of keywords including low birth weight, guidelines, barriers, attitude, beliefs, maternal health/nutrition, health services utilisation, satisfaction and quality of care. Additional articles were identified and retrieved by reviewing the reference list of relevant articles, while further reports and materials from organisations and governments were identified manually and found online.

Only English language papers published between 2000 and 2016 were included. Articles pertaining to women with co-morbidities were excluded, as separate sets of guidelines often exist for these women. Besides the WHO guidelines, only studies relating to Vietnam were included. Furthermore, only studies related to antenatal care (ANC), perinatal care, postnatal care (PNC) and breastfeeding practices were included, with a focus on LBW. The critical evaluation of studies included looking at the study methodology, perceived objectivity, study provenance, research evidence, and the contribution of the study to the literature.

The review was conducted by the author from February to June 2016 as part of a master’s thesis. Subsequently, the Ministry of Health (MoH) Vietnam has launched The National Guideline on nutrition for pregnant women and lactating mothers, acting as a practical step for effective implementation of the National Nutrition strategy 2011-2020 with a vision toward 2030. The WHO has since updated their recommendations on newborn health, but no significant changes occurred with regards to the included guidelines.

Results

Variance between WHO guidelines and national guidelines in Vietnam

Differences between the WHO’s guidelines and national guidelines in Vietnam were analysed to identify whether Vietnam follows the evidence-based guidelines proposed by the WHO, and to determine whether both sets of guidelines are appropriate considering the national context. As shown in Table 1 below, national guidelines in Vietnam are largely in agreement with WHO guidelines. However, significant disagreements exist, and are highlighted in the table.

Barriers to guideline implementation in Vietnam

1. Health sector

Structural components, including health facilities,[43] staff[44, 45] and basic equipment for reproductive health care,[46] are lacking mostly in rural areas. The Joint Annual Health Review 2015 conducted by the MoH Vietnam and Health Partnership Group suggested that restricted health financing may impede improvement.[47] Health funds are allocated via input indicators (number of beds and staff). Thus, rural areas are faced with smaller hospitals and fewer staff. At a commune and district level, less funding is relatively available, and investments are rather made in high-tech equipment such as ultrasound.[47]

A study by Eriksson et al. involving 412 primary health care practitioners found availability of national guidelines for reproductive health care similar across hospitals (67%) and community health centres (70%) in northern Vietnam.[48] However, in a study by Trevisanuto et al. conducted in South/South Central Vietnam, only half of clinical practitioners from provincial level hospitals deemed written guidelines ‘very important’.[49] Despite a limited sample size (n=54) including a mix of professional backgrounds (nurses, midwives, doctors), the majority of the sample were considered local experts in neonatal infections. Though content of national guidelines was considered relevant by such professionals, they were rarely used.[50] Furthermore, Eriksson et al found no association between level of knowledge of neonatal care and access to guidelines.[48] This suggests limited knowledge and utilisation of guidelines despite availability.[48] Thus, a need for stronger implementation strategies and/or more context appropriate guidelines is necessary.

In-service and competency-based training as well as the quality of health workers’ performance is also unequally distributed between urban and rural areas[46-48, 51-57], particularly for infant feeding practices.[57-61] This is primarily due to working conditions and the lack of compensation for time spent on training, in addition to a paucity of career development opportunities.[46, 50, 52] In contrast, one study by Eriksson et al., found relatively high knowledge scores on LBW care and early breastfeeding among health workers[48] which could contribute to reducing LBW morbidity and mortality.

Structural components, including health facilities [43], staff[44, 45] and basic equipment for reproductive health care[46], are lacking mostly in rural areas. The Joint Annual Health Review 2015 conducted by MoH Vietnam and Health Partnership Group suggested that impedance to improvement stems from restricted health financing.[47] Health funds are allocated via input indicators (number of beds and staff). Thus, rural areas are faced with smaller hospitals and fewer staff. At a commune and district level, less funding is relatively available, and investments are rather made in high-tech equipment such as ultrasound.[47]

2. Mothers and cultural factors

Another cultural factor often overlooked is the occurrence of home births, particularly in rural areas.[40, 43] Homebirths are preferred by patients given lower costs and travel. However, they are also related to a higher prevalence of LBW and neonatal mortality.[67, 68] Such births are often chosen to avoid embarrassment and stigmatisation in cases of non-marital status or lack of knowledge. Furthermore, the convenience of local family support[69] or adherence to cultural traditions favour home births in rural areas.[55, 69] In contrast, urban mothers tend to over-use technology, with a strong preference for birth via caesarean section (CS)[53, 67, 68]. CS has been associated with poorer rates[55, 70, 71] and durations of EBF,[68, 72] thus having negative consequences for breastfeeding practices.

EBF and lactation mechanisms are often poorly understood and under-appreciated amongst mothers, relatives and lay persons.[59, 70, 71, 73-76] An example is the low value placed on colostrum – a vital dietary component for the LBW infant.[59, 71, 72, 77-80] Whilst women traditionally follow postpartum rituals passed on from grandmothers and other surrounding mothers[57, 58, 73], these breastfeeding practices may be dangerous and suboptimal due to feeding of water [71, 78] and the perception that breastmilk is insufficient in quantity and quality.[59, 71, 77, 78] Such practices may increase the risk of poor postnatal outcomes,[57-60, 73, 80] as the LBW infant does not receive vital nutrients from colostrum that stimulate the development of the infant’s digestive system, antibodies and white blood cells.[71]

Two different scenarios were found for breastfeeding in Vietnam. For rural areas, women with high education tend to breastfeed longer than women with lower education. On the contrary, highly educated women in urban areas tend to breastfeed for a shorter duration and non-exclusively.[68, 72, 76] Thus, higher educational level improves breastfeeding practices in rural areas, but presents as a barrier in urban areas. This may be due to exposure to mass media and infant formula advertisements, amongst other reasons yet to be explored.[71, 81, 82]

Despite guideline discouragement,[40] pre-lacteal feeds[57, 59, 71, 73-75] and complementary feeding[83, 84] are often given before the 6 months of exclusive breastfeeding ends. Interestingly, the cultural preference for sons has caused a disparity between breastfeeding practices in male and female infants. Due to the belief that breastfeeding is inferior to formula milk, males are breastfed less often.[68, 85] This is often a belief carried by the whole family and undermines the importance of EBF, meaning that emphasis must be placed on familial involvement and education to encourage breastfeeding practices and prevent morbidity and mortality due to LBW.[79, 80, 86]

3. Inconsistent and confounding policies for LBW prevention and care

The International Code of Marketing of Breastmilk Substitutes is enacted in Vietnam.[87] However, implementation has been challenging,[88-90] and the International Baby Food Action Network along with the WHO and UNICEF have identified common violations, such as biased/inaccurate advertisements, improper labelling and promotion of complementary infant foods.[91, 92] Health workers are often approached by formula companies to promote complementary foods from which they receive commission.[55, 58, 71, 93] Such practices have adverse consequences on promotion of healthy infant feeding practices[58, 60, 71, 76, 93, 94], thus hindering breastfeeding practices and the health and survival of LBW infants.

Confounding policies regarding maternity leave are also contributing to suboptimal LBW prevention and care. Since 2012, maternity leave has been 4-6 months, which is longer than the recommended 14 weeks proposed by the International Labor Organisation.[95] However, the unpaid nature of maternity leave has been found to be a barrier to EBF. [84, 93] Casual or temporary workers find it necessary to return to work given financial responsibilities, thus necessitating complementary infant foods.[59, 71, 73, 74, 77, 79]

Discussion

As evident from this study, developing coherent guidelines and aligning strategies preventing LBW is difficult at national and international levels. Even more challenging is implementation of such guidelines in countries with high prevalence of LBW and neonatal morbidity and mortality. Appropriate evidence-based guidelines have the potential to promote beneficial interventions and discourage ineffective medical practice.[96] Their appropriateness for prevention and management of LBW infants in Vietnam will therefore be discussed.

Appropriate cut-off for referral of LBW

Different cut-offs for referral of LBW infants were found in two current WHO WPR documents: a 2000g cut-off and a 1500g cut-off in the WHO WPR Action Plan 2014-2020[37] and the WHO WPR EENC guide (2014),[97, 98] respectively. This demonstrates intra-organisation disparity. The 2000g cut-off in Vietnam seems to be more appropriate, due to the seemingly lower risk of mortality associated with the 2000g threshold when compared to 1500g. On the other hand, a 1500g cut-off may be more easily adaptable to the context given high ANC coverage in Vietnam. However, high coverage does not always mean high quality of care.[98] Thus, rather than debating between cut-off values, focus should remain on intensifying quality care for LBW infants whilst reducing unnecessary CS as recommended by the WHO WPR Action Plan.[37]

Qualifying as an LBW infant might not necessarily increase risk of mortality – a phenomenon known as the LBW paradox.[99, 100] In Vietnam, factors such as high altitude may be a risk factor for LBW, but not necessarily for mortality.[99, 100] Knowledge of the predominant distribution (weight distribution of term births) and the residual distribution (percentage of small and preterm births) is essential in gaining insight into the gestational-age characteristics. Epidemiological data is needed to provide a better basis to judge the appropriateness of cut-off values.

Appropriate number and timing of ANC visits

Despite the WHO recommending 4 ANC visits,[35] the exact timing of ANC visits has been debated.[101] Current recommendations are based on a large WHO ANC randomized trial comparing the standard model of ANC (12 visits) with the new ANC model (4 visits). No differences in maternal and perinatal outcomes were found between the two models.[102] A systematic review of studies from developed and developing countries provided similar findings

where good perinatal outcomes persisted despite reduced ANC visits.[103] However, it proposed that in a setting of low ANC coverage, visits should not be reduced without close monitoring of foetal and neonatal outcomes.[103]

There is no current documentation of 3 visits being equal to or better than 4. One argument for increasing the number of ANC visits from 3 to 4 would be the relatively high contribution of neonatal mortality to under-5 mortality in Vietnam. One-third of neonatal deaths are estimated to be caused by prematurity,[104] including a proportion of LBW infants, for which higher frequency of ANC visits could be beneficial. Further supporting arguments include the relatively high maternal malnutrition rates that could be potentially addressed through increased counselling by clinicians. Increasing visitation might facilitate breastfeeding education and allow healthcare providers to detect and counsel women at risk of prematurity and LBW. However, this requires further investigation.

Nevertheless, recommending 4 ANC visits comes with increased societal costs as well as costs to the mother via transportation and loss of working hours for mothers without access to free reproductive health services. This potentially increases disparities between urban and rural areas where socioeconomic standing differs. Therefore, changes in policy and practice should be closely monitored. Outcomes including monitoring of customer (mother) and provider (healthcare worker) satisfaction should be monitored alongside trends in peri- and post-partum morbidity and mortality.

Appropriate number and timing of PNC visits

A Cochrane review conducted by Yonemoto et al. found no strong evidence on the association between number and timing of home-visits and improvements in neonatal and maternal mortality.[105] However, the review found 4 studies with evidence suggesting that home visits may encourage women to participate in EBF. An association between home visits and increased maternal satisfaction with postnatal care was also described, which suggests that PNC is beneficial in alleviating the burden of LBW. Unlike the WHO, the MoH in Vietnam does not recommend a PNC visit at 7-14 days. Considering the high neonatal mortality within the first week of life,[106, 107] the low rate of EBF, the importance of managing potential infections and educating mothers in nutrition/feeding practices for LBW infants, recommending a PNC visit at 7-14 days could be appropriate. This should be considered only after evaluating the availability of resources and assessing morbidity and mortality risk within the first week of life. To date, it remains unknown if a PNC visit at 7-14 days is appropriate in Vietnam. Furthermore, the current Vietnamese PNC schedule articulates well with the Expanded Programme on Immunisation.[108] Similar to ANC, the focus should be on content and quality of care to facilitate optimal breastfeeding practices as opposed to increasing PNC visits, which may incur economic and consumer costs.

Discussion of strengths and limitations

While based on secondary data and guidelines supplied by key stakeholders, it is assumed that the retrieved guidelines represent the current state of guidelines for LBW and associated barriers and implementation. However, a literature review is dependent on the current state of research. The reviewed research into LBW is limited, especially with regards to guidelines in Vietnam, which sometimes display contradiction. Small sample sizes in the individual studies reviewed may have further limited the validity, reliability and generalisability of this study. Larger and prospective studies of current practice and potential improvements are recommended, but with a focus on the actual users of current guidelines, such as first-line healthcare workers and the women, before, during and after birth. Persistently high rates of neonatal morbidity and mortality in Vietnam call for future studies to address relatively simple questions, including the discrepancy between available guidelines regarding ANC frequency and the threshold of referral.

Conclusion

Guidelines on ANC, perinatal care, PNC and breastfeeding for LBW infants weighing between 1500-2500g were available and accessible in Vietnam. Structural factors, including culture, infrastructure and economy, appeared to be major barriers to implementation and acceptance of guidelines.

The appropriateness of LBW guidelines requires

further research. In the context of relatively high neonatal mortality, four ANC visits in Vietnam might be more appropriate than three. In line with recommendations by the WHO, breastfeeding and skin-to-skin contact were found appropriate for Vietnam given their potential to reduce the burden of LBW morbidity and mortality in low-resource settings. The internal institutional alignment and coherence of guidelines, particularly the cut-off for referral of LBW infants, should also be monitored to ensure healthcare workers are appropriately informed of practices and the complications of nonadherence. Further studies comparing divergent WHO guidelines, local guidelines and local cultural norms and traditions are recommended.

 

 

Acknowledgements

The author would like to thank her supervisor Professor Ib Bygbjerg, Priya Mannava, and Dr. Ashraful (Neeloy) Alam for their guidance, advice and support.

Declarations

The materials used and analysed during the current study are available from the author upon reasonable request.

Conflicts of interest

None declared

Correspondence

linemp89@gmail.com

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