| 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 |
