Multilevel Disparities and Challenges in Maternal and Neonatal Health Across Healthcare Facility Levels in Northern Vietnam: A Mixed-Methods Study

Neonatal mortality in Vietnam remains unacceptably high, particularly in remote or socioeconomically disadvantaged areas. Although quantitative metrics can reveal outcome discrepancies, they often do not capture contextual challenges such as limited inter-facility coordination or cultural constraints. This mixed methods study aimed to understand how facility-level factors influence neonatal outcomes. We retrospectively analyzed records from 1978 mother-infant pairs across four levels of Vietnam’s health system: a central-level, a provincial-level, a district-level, and a commune-level facility in Northern Vietnam, focusing on stillbirth rates, birth interventions, and Apgar scores. We then conducted focus group discussions with six obstetricians and seven midwives to gain insights into the relevant healthcare system. We integrated both data streams using a joint display, contextualizing the regression findings alongside qualitative themes. Quantitative findings showed that cesarean section rates at the central-level (12.2%) were higher than at the provincial-level (9.3%), the district-level (7.3%), and the commune-level (0%) and labor induction also occurred most frequently at the central level (11.9%). In contrast, commune-level health stations recorded the highest stillbirth prevalence (6.7%) and lower median Apgar scores. Qualitative insights underscored inadequate referral pathways, workforce constraints, and limited training opportunities as pivotal contributors to neonatal risks. Addressing these issues requires targeted policy and operational measures, including equitable resource allocation, sustained skill‑building programs, and improved referral networks. By uniting numerical indicators with health providers’ perspectives, our study highlights the multifaceted nature of neonatal care disparities. It offers actionable strategies to reduce newborn deaths, fostering more significant equity across Vietnam’s healthcare landscape.