progress and challenges in maternal health in western china a countdown to 2015 national CORD-Papers-2022-06-02 (Version 1)

Title: Progress and challenges in maternal health in western China: a Countdown to 2015 national case study
Abstract: BACKGROUND: China is one of the few Countdown countries to have achieved Millennium Development Goal 5 (75% reduction in maternal mortality ratio between 1990 and 2015). We aimed to examine the health systems and contextual factors that might have contributed to the substantial decline in maternal mortality between 1997 and 2014. We chose to focus on western China because poverty ethnic diversity and geographical access represent particular challenges to ensuring universal access to maternal care in the region. METHODS: In this systematic assessment we used data from national census reports National Statistical Yearbooks the National Maternal and Child Health Routine Reporting System the China National Health Accounts report and National Health Statistical Yearbooks to describe changes in policies health financing health workforce health infrastructure coverage of maternal care and maternal mortality by region between 1997 and 2014. We used a multivariate linear regression model to examine which contextual and health systems factors contributed to the regional variation in maternal mortality ratio in the same period. Using data from a cross-sectional survey in 2011 we also examined equity in access to maternity care in 42 poor counties in western China. FINDINGS: Maternal mortality declined by 89% per year between 1997 and 2014 (geometric mean ratio for each year 091 95% CI 091092). After adjusting for GDP per capita length of highways female illiteracy the number of licensed doctors per 1000 population and the proportion of ethnic minorities the maternal mortality ratio was 118% higher in the western region (218 144328) and 41% higher in the central region (141 099201) than in the eastern region. In the rural western region the proportion of births in health facilities rose from 419% in 1997 to 984% in 2014. Underpinning such progress was the Government's strong commitment to long-term strategies to ensure access to delivery care in health facilitieseg professionalisation of maternity care in large hospitals effective referral systems for women medically or socially at high risk and financial subsidies for antenatal and delivery care. However in the poor western counties substantial disparity by education level of the mother existed in access to health facility births (44% of illiterate women vs 100% of those with college or higher education) antenatal care (17% vs 69%) had at least four visits) and caesarean section (8% vs 44%). INTERPRETATION: Despite remarkable progress in maternal survival in China substantial disparities remain especially for the poor less educated and ethnic minority groups in remote areas in western China. Whether China's highly medicalised model of maternity care will be an answer for these populations is uncertain. A strategy modelled after China's immunisation programme whereby care is provided close to the women's homes might need to be explored with township hospitals taking a more prominent role. FUNDING: Government of Canada UNICEF and the Bill & Melinda Gates Foundation.
Published: 2017-03-21
Journal: Lancet Glob Health
DOI: 10.1016/s2214-109x(17)30100-6
DOI_URL: http://doi.org/10.1016/s2214-109x(17)30100-6
Author Name: Gao Yanqiu
Author link: https://covid19-data.nist.gov/pid/rest/local/author/gao_yanqiu
Author Name: Zhou Hong
Author link: https://covid19-data.nist.gov/pid/rest/local/author/zhou_hong
Author Name: Singh Neha S
Author link: https://covid19-data.nist.gov/pid/rest/local/author/singh_neha_s
Author Name: Powell Jackson Timothy
Author link: https://covid19-data.nist.gov/pid/rest/local/author/powell_jackson_timothy
Author Name: Nash Stephen
Author link: https://covid19-data.nist.gov/pid/rest/local/author/nash_stephen
Author Name: Yang Min
Author link: https://covid19-data.nist.gov/pid/rest/local/author/yang_min
Author Name: Guo Sufang
Author link: https://covid19-data.nist.gov/pid/rest/local/author/guo_sufang
Author Name: Fang Hai
Author link: https://covid19-data.nist.gov/pid/rest/local/author/fang_hai
Author Name: Alvarez Melisa Martinez
Author link: https://covid19-data.nist.gov/pid/rest/local/author/alvarez_melisa_martinez
Author Name: Liu Xiaoyun
Author link: https://covid19-data.nist.gov/pid/rest/local/author/liu_xiaoyun
Author Name: Pan Jay
Author link: https://covid19-data.nist.gov/pid/rest/local/author/pan_jay
Author Name: Wang Yan
Author link: https://covid19-data.nist.gov/pid/rest/local/author/wang_yan
Author Name: Ronsmans Carine
Author link: https://covid19-data.nist.gov/pid/rest/local/author/ronsmans_carine
sha: 63f217fcfcfa2946363e2ddb52fc7acaae72b466
license: cc-by
license_url: https://creativecommons.org/licenses/by/4.0/
source_x: Elsevier; Medline; PMC
source_x_url: https://www.elsevier.com/https://www.medline.com/https://www.ncbi.nlm.nih.gov/pubmed/
pubmed_id: 28341117
pubmed_id_url: https://www.ncbi.nlm.nih.gov/pubmed/28341117
pmcid: PMC5387688
pmcid_url: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5387688
url: https://api.elsevier.com/content/article/pii/S2214109X17301006 https://doi.org/10.1016/s2214-109x(17)30100-6 https://www.sciencedirect.com/science/article/pii/S2214109X17301006 https://www.ncbi.nlm.nih.gov/pubmed/28341117/
has_full_text: TRUE
Keywords Extracted from Text Content: women mother 1·41 highways GDP Yearbooks Women caesarean sections centives Hai Fang Powell-Jackson p=0·00021 pregnant women Investments ¥ § funds appendix p 3 woman 1·41 magnesium sulphate appendix p 16 2·2 UNICEF PubMed milk appendix pp [6] [7] [8] [9] appendix p 10 † Tibetan GDP appendix pp 4-5 MDG5 highways people US$ NSS measles SN Guizhou appendix p 15 Human Resources TP-J appendix p 17 maternal health care †Further 10·9 www.thelancet.com/lancetgh Vol 5 ¥13 228 haemoglobin Jilin eye ointment health-such DPT3 appendix p 12 water 9·8 UK counties 15·2 Min Yang Carine Ronsmans appendix NSS, HF tetanus blood left oxygen MDG4 appendix p 2 children Shanxi province human residents mother 11·3 appendix pp [4] [5] . cord diphtheria 99·9 10·7 Neha S Singh sections appendix pp 6, 11 appendix p 18 Hebei province building-have oxytocin surfactant 108·7 hepatitis B appendix p 14 USA-about vaginal fetal appendix p 1 ¥27 104 women cup p<0·05 MY Tibet km2 Yearbooks Bill OPP1058954 UNICEF
Extracted Text Content in Record: First 5000 Characters:Background China is one of the few Countdown countries to have achieved Millennium Development Goal 5 (75% reduction in maternal mortality ratio between 1990 and 2015). We aimed to examine the health systems and contextual factors that might have contributed to the substantial decline in maternal mortality between 1997 and 2014. We chose to focus on western China because poverty, ethnic diversity, and geographical access represent particular challenges to ensuring universal access to maternal care in the region. Health Statistical Yearbooks to describe changes in policies, health financing, health workforce, health infrastructure, coverage of maternal care, and maternal mortality by region between 1997 and 2014. We used a multivariate linear regression model to examine which contextual and health systems factors contributed to the regional variation in maternal mortality ratio in the same period. Using data from a cross-sectional survey in 2011, we also examined equity in access to maternity care in 42 poor counties in western China. Findings Maternal mortality declined by 8·9% per year between 1997 and 2014 (geometric mean ratio for each year 0·91, 95% CI 0·91-0·92). After adjusting for GDP per capita, length of highways, female illiteracy, the number of licensed doctors per 1000 population, and the proportion of ethnic minorities, the maternal mortality ratio was 118% higher in the western region (2·18, 1·44-3·28) and 41% higher in the central region (1·41, 0·99-2·01) than in the eastern region. In the rural western region, the proportion of births in health facilities rose from 41·9% in 1997 to 98·4% in 2014. Underpinning such progress was the Government's strong commitment to long-term strategies to ensure access to delivery care in health facilities-eg, professionalisation of maternity care in large hospitals, effective referral systems for women medically or socially at high risk, and financial subsidies for antenatal and delivery care. However, in the poor western counties, substantial disparity by education level of the mother existed in access to health facility births (44% of illiterate women vs 100% of those with college or higher education), antenatal care (17% vs 69%) had at least four visits), and caesarean section (8% vs 44%). Interpretation Despite remarkable progress in maternal survival in China, substantial disparities remain, especially for the poor, less educated, and ethnic minority groups in remote areas in western China. Whether China's highly medicalised model of maternity care will be an answer for these populations is uncertain. A strategy modelled after China's immunisation programme, whereby care is provided close to the women's homes, might need to be explored, with township hospitals taking a more prominent role. At the end of 2015, the Millennium Development Goals (MDGs) came to a close. Much progress has been achieved for MDG4, with 25 of the 75 Countdown to 2015 priority countries achieving a two-thirds reduction in child mortality. 1 Far fewer countries achieved the MDG5 target to reduce the maternal mortality ratio by threequarters. 1 To better understand the factors that might have enabled or hindered progress for maternal and child health, Countdown commissioned several in-depth country case studies, 1 including one for China. China's progress in maternal and child survival in the past 20 years has been impressive. 2 China has achieved the fastest reduction in under-5 mortality among Countdown countries, 1 realising the MDG4 target with an under-5 mortality of 10·7 deaths per 1000 livebirths in 2015. 3 Reductions in maternal mortality have been equally impressive, and nearly all women now deliver in health facilities. [3] [4] [5] The maternal mortality ratio in 2014 was 21·7 deaths per 100 000 livebirths, signalling that China has achieved MDG5. 3 At an international Countdown forum in Beijing (China) in October, 2015, China examined its progress in maternal and child survival. 3 Although there was undeniable cause for celebration, persistent regional disparities in maternal and child health, e524 www.thelancet.com/lancetgh Vol 5 May 2017 particularly in the rural and remote regions of western China, have also been recognised. [6] [7] [8] In this case study, we aimed to explore reasons for progress in maternal survival in China, examining the health systems and contextual factors that might have contributed to the substantial decline in maternal mortality between 1997 and 2014. We chose to focus on western China, a region where poverty, ethnic diversity, and geographical access represent particular challenges to ensuring universal access to maternal care. We also examined equity in access along the continuum of care among women and children in rural western China, so as to inform strategies for further improvements in maternal health in the region. Equity in access is important, not only because aggregate geographical data can hide individual variation, but also because
Keywords Extracted from PMC Text: 10·7 population.52 left human 99·9 Neha S Singh services.38 fetal recognised.6 mother 2000–12.30 then.12 MDG4 charges.38 1·41 2·2 ChinaIn causes".16 measles p<0·05 diphtheria gap.45 Jilin appendix pp 4–5 below.51 health.36 ratio.25 funds appendix p 15 Hebei province tetanus hepatitis B centre oxytocin DPT3 China.84 reports13 GDP pregnant women appendix p 2 7, 8 Research in context Evidence before this case.68 expenses.44 NSS ¥ maternal health care appendix p 1 blood 10·9 MY woman Human Resources ( people Women appendix p 16 2000.24 Shanxi province counties Tibetan appendix p 10 TP-J Liaoning, household).38 time.58 countries,1 UNICEF SN appendix p 14 Tibet enrolment.43 1·4 appendix p 12 appendix pp 6, 11 MDG5.3 ¥13 228 vaginal women caesarean sections appendix p 3 highways systems),50 sections three-quarters.1 appendix antenatal visits.27 birth.59 China appendix p 17 measures.31 95%.85 MDG5 3·0 institutions US$ p=0·00021 water 0·93–0·96 appendix p 18 1995–2000 surfactant studies,1 11·3 ¥27 104 15·2 magnesium sulphate communities.79 children births.23 surveys5 Min Yang NSS, HF PubMed Investments China.41 China's 9·8 108·7 haemoglobin Guizhou Powell-Jackson Hai Fang governments.38 packages.38 Children residents— UK
Extracted PMC Text Content in Record: First 5000 Characters:At the end of 2015, the Millennium Development Goals (MDGs) came to a close. Much progress has been achieved for MDG4, with 25 of the 75 Countdown to 2015 priority countries achieving a two-thirds reduction in child mortality.1 Far fewer countries achieved the MDG5 target to reduce the maternal mortality ratio by three-quarters.1 To better understand the factors that might have enabled or hindered progress for maternal and child health, Countdown commissioned several in-depth country case studies,1 including one for China. China's progress in maternal and child survival in the past 20 years has been impressive.2 China has achieved the fastest reduction in under-5 mortality among Countdown countries,1 realising the MDG4 target with an under-5 mortality of 10·7 deaths per 1000 livebirths in 2015.3 Reductions in maternal mortality have been equally impressive, and nearly all women now deliver in health facilities.3, 4, 5 The maternal mortality ratio in 2014 was 21·7 deaths per 100 000 livebirths, signalling that China has achieved MDG5.3 At an international Countdown forum in Beijing (China) in October, 2015, China examined its progress in maternal and child survival.3 Although there was undeniable cause for celebration, persistent regional disparities in maternal and child health, particularly in the rural and remote regions of western China, have also been recognised.6, 7, 8 Research in context Evidence before this study We searched PubMed for all original research articles published in English or Chinese between Jan 1, 1997, and Dec 31, 2015, using the search term "([maternal mortality]) AND China". Of 603 papers identified, 22 empirically addressed maternal health and health-care issues at the regional or national level or inequalities in access to maternal care across socioeconomic groups. Results from these studies confirmed the substantial decline in maternal mortality in China over the past 20 years and also showed the persistent gap between the eastern, central, and western regions. Factors such as educational achievements, household income, traditions, and geographical access were found to be determinants of uptake of hospital delivery care. However, no study provided a systematic analysis of the health systems inputs and outputs that might explain the regional variation in maternal mortality in China, and no study examined inequalities in access to maternal health care among the poorest population groups. Added value of this study We used the standard framework developed by Countdown to 2015's Health Systems and Policies Working Group to examine the health systems and contextual factors that might have contributed to the substantial decline in maternal mortality between 1997 and 2014. We took advantage of a unique data source on the maternal mortality ratio collected by the Chinese National Health and Family Planning Commission from 1997 to 2014 for all 31 provinces in China and a population-based survey in 42 poor counties in western China in 2011. We examined equity in access along the continuum of care among women and children in rural western China to inform strategies for further improvements in maternal health in the region, as well as time trends and regional variation in maternal mortality ratio between 1997 and 2014. Implications of the available evidence Many countries can learn lessons from China's remarkable improvement in maternal survival. Central to China's progress has been a firm commitment from the Government to long-term strategies to ensure access to delivery care in health facilities, with a strong focus on the professionalisation of maternity care in large hospitals, effective referral systems for women at high risk, and financial subsidies for antenatal and delivery care. The Chinese Government was also able to implement its policies with enough authority and accountability to make professional delivery care accessible to all women. As China is on the road to achieving the Sustainable Development Goals, attention now needs to be paid to the unmet need of those not yet able to access care: the poor, less educated, and ethnic minority groups in remote areas in western China. In this case study, we aimed to explore reasons for progress in maternal survival in China, examining the health systems and contextual factors that might have contributed to the substantial decline in maternal mortality between 1997 and 2014. We chose to focus on western China, a region where poverty, ethnic diversity, and geographical access represent particular challenges to ensuring universal access to maternal care. We also examined equity in access along the continuum of care among women and children in rural western China, so as to inform strategies for further improvements in maternal health in the region. Equity in access is important, not only because aggregate geographical data can hide individual variation, but also because China is the only Countdown country that does not report individual so
PDF JSON Files: document_parses/pdf_json/63f217fcfcfa2946363e2ddb52fc7acaae72b466.json
PMC JSON Files: document_parses/pmc_json/PMC5387688.xml.json
G_ID: progress_and_challenges_in_maternal_health_in_western_china_a_countdown_to_2015_national