Dominant Factors Affecting Regional Inequality of Infant Mortality in Vietnam: A Structural Equation Modelling Analysis

Document Type: Original Article


1 Department of Medical Services Administration, Ministry of Health, Hanoi, Vietnam

2 Queensland University of Technology, Brisbane, QLD, Australia

3 School of Nursing, Indiana University, Bloomington, IN, USA


Despite Vietnam’s acclaiming achievements of reducing overall infant mortality rate (IMR), the IMR decline does not occur equally in all regions in Vietnam. This study aims to investigate dominant factors that affect the inequality of infant mortality across regions in Vietnam during the period 2005-2015.

We use nationally representative data to construct a panel data of 6 economic regions in Vietnam from 2005 to 2015. We employ the structural equation modelling (SEM) approach to quantify the causal effect of socio-economic status (SES), accessing to skilled birth attendance (SBA) and other relevant factors on the disparity of IMR across regions.

SES, which is measured by 3 indicators – illiteracy rate (IR), poverty rate (PR) and income per capita – is the dominant factor causing regional inequalities of infant mortality, followed by the use of SBA. Among these indicators, the PR is the most important one causing the regional disparity of IMR and accessing to SBA. The total effect of SES on infant mortality disparity is 2.6 times as high as that of accessing skilled healthcare personnel.

Bridging the regional gap of using skilled health personnel would contribute to improving the infant mortality inequality in Vietnam. This inequality, however, is not significantly improved only with medical interventions but also with broader and more comprehensive socio-economic interventions at both national and regional levels. Our findings confirm that poverty reduction and growth strategies should be the main focus to boost medical interventions and improve IMR all over the country.



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  1. General Statistics Office. Statistics Yearbook. 2005-2017.  Accessed January 2019.
  2. World Health Organization (WHO). Definition of Skilled Health Personnel Providing Care During Childbirth: The 2018 Joint Statement by WHO, UNFPA, UNICEF, ICM, ICN, FIGO, IPA. WHO; 2018.
  3. Vietnam Ministry of Health. National Plan of Action for Child Survival 2009–2015. Hanoi: Vietnam Ministry of Health; 2009.
  4. Vietnam Ministry of Health. Health Statistics Yearbook. Hanoi: Vietnam Ministry of Health; 2005-2015.
  5. Socialist Republic of Vietnam. 15 Years Achieving the Vietnam Millennium Development Goals. Vietnam: Socialist Republic of Vietnam; 2015.
  6. Do M. Utilization of skilled birth attendants in public and private sectors in Vietnam. J Biosoc Sci. 2009;41(3):289-308. doi:10.1017/s0021932009003320
  7. Chuong NC, Van Minh H, Thi Thuy Duong D, Duc DM, Anh Dao LT, Duy Anh N. Progress on maternal health care in Vietnam: findings from Vietnam Multiple Indicator Cluster Survey 2000, 2006, 2011, and 2014. Health Care Women Int. 2018;39(4):368-376. doi:10.1080/07399332.2017.1405960
  8. Målqvist M, Lincetto O, Du NH, Burgess C, Hoa DT. Maternal health care utilization in Vietnam: increasing ethnic inequity. Bull World Health Organ. 2013;91(4):254-261. doi:10.2471/blt.12.112425
  9. Lee HY, Van Do D, Choi S, Trinh OT, To KG. Trends and determinants of infant and under-five childhood mortality in Vietnam, 1986-2011. Glob Health Action. 2016;9:29312. doi:10.3402/gha.v9.29312
  10. UNICEF. SDGs and Children in Vietnam. Hanoi, Vietnam: UNICEF; 2018.
  11. O'Hare B, Makuta I, Chiwaula L, Bar-Zeev N. Income and child mortality in developing countries: a systematic review and meta-analysis. J R Soc Med. 2013;106(10):408-414. doi:10.1177/0141076813489680
  12. Brownell M, Enns J. Reducing child mortality in high-income countries: where to from here? Lancet. 2018;391(10134):1968-1969. doi:10.1016/s0140-6736(18)30938-3
  13. Pritchard C, Keen S. Child mortality and poverty in three world regions (the West, Asia and Sub-Saharan Africa) 1988-2010: evidence of relative intra-regional neglect? Scand J Public Health. 2016;44(8):734-741. doi:10.1177/1403494816675550
  14. Badiani R, Baulch B, Brandt L, et al. 2012 Vietnam Poverty Assessment: Well Begun, Not Yet Done - Vietnam's Remarkable Progress on Poverty Reduction and the Emerging Challenges. 2013. Published 2013.
  15. StatSoft Inc. Electronic Statistics Textbook.  Accessed July 20, 2019. Published 2013.
  16. Kline RB. Principles and Practice of Structural Equation Modeling. 4th ed. New York: The Guilford Press; 2016.
  17. Hooper D, Coughlan J, Mullen MR. Structural equation modelling: guidelines for determining model fit. Elecron J Bus Res Methods. 2008;6(1):53-60.
  18. Idrovo AJ. Three criteria for ecological fallacy. Environ Health Perspect. 2011;119(8):A332. doi:10.1289/ehp.1103768
  19. Say L, Raine R. A systematic review of inequalities in the use of maternal health care in developing countries: examining the scale of the problem and the importance of context. Bull World Health Organ. 2007;85(10):812-819. doi:10.2471/blt.06.035659
  20. Gill CJ, Phiri-Mazala G, Guerina NG, et al. Effect of training traditional birth attendants on neonatal mortality (Lufwanyama Neonatal Survival Project): randomised controlled study. BMJ. 2011;342:d346. doi:10.1136/bmj.d346
  21. Houweling TA, Caspar AE, Looman WN, Mackenbach JP. Determinants of under-5 mortality among the poor and the rich: a cross-national analysis of 43 developing countries. Int J Epidemiol. 2005;34(6):1257-1265. doi:10.1093/ije/dyi190
  22. Gebretsadik S, Gabreyohannes E. Determinants of under-five mortality in high mortality regions of Ethiopia: an analysis of the 2011 Ethiopia Demographic and Health Survey data. Int J Popul Res. 2016;2016:1602761. doi:10.1155/2016/1602761
  23. Department of Economic and Social Affairs, Population Division. World Mortality Report 2015. United Nations; 2017.
  24. Afulani PA, Moyer C. Explaining disparities in use of skilled birth attendants in developing countries: a conceptual framework. PLoS One. 2016;11(4):e0154110. doi:10.1371/journal.pone.0154110
  25. World Health Organization. Human Resources for Health, Country Profiles: Vietnam. Manila: WHO Regional Office for the Western Pacific; 2016.
  26. Singh K, Brodish P, Suchindran C. A regional multilevel analysis: can skilled birth attendants uniformly decrease neonatal mortality? Matern Child Health J. 2014;18(1):242-249. doi:10.1007/s10995-013-1260-7
  27. Say L, Raine R. A systematic review of inequalities in the use of maternal health care in developing countries: examining the scale of the problem and the importance of context. Bull World Health Organ. 2007;85(10):812-819. doi:10.2471/blt.06.035659
  28. United Nations Population Fund (UNFPA). Reaching Out to Minorities in Viet Nam with Midwives who Speak their Language. UNFPA; 2010.
  29. McGovern ME, Canning D. Vaccination and all-cause child mortality from 1985 to 2011: global evidence from the Demographic and Health Surveys. Am J Epidemiol. 2015;182(9):791-798. doi:10.1093/aje/kwv125
  30. Breiman RF, Streatfield PK, Phelan M, Shifa N, Rashid M, Yunus M. Effect of infant immunisation on childhood mortality in rural Bangladesh: analysis of health and demographic surveillance data. Lancet. 2004;364(9452):2204-2211. doi:10.1016/s0140-6736(04)17593-4
  31. National Institute of Hygiene and Epidemiology (NIHE). Achievements of Expand Program Immunization 2011.  Accessed July 27, 2019. Published 2011.
  32. John TJ, Samuel R. Herd immunity and herd effect: new insights and definitions. Eur J Epidemiol. 2000;16(7):601-606. doi:10.1023/a:1007626510002