Ethnic disparities and temporal trends in health resource allocation: a retrospective decadal analysis in Sichuan, a multi-ethnic Province of Southwest China (2009-2019)

BACKGROUND

Research on health resource allocation trends in ethnic minority and impoverished areas in China is limited since the 2009 Medical Reform. This study aimed to investigate the variations and inequalities in health resource distribution among ethnic minority, poverty-stricken, and non-minority regions in Sichuan Province, a multi-ethnic province in Southwest China, from 2009 to 2019.

METHODS

The numbers of beds, doctors and nurses were retrospectively sourced from the Sichuan Health Statistics Yearbook between 2009 and 2019. All the 181 counties in Sichuan Province were categorized into five groups: Yi, Zang, other ethnic minority, poverty-stricken, and non-minority county. The Theil index, adjusted for population size, was used to evaluate health resource allocation inequalities.

RESULTS

From 2009 to 2019, the number of beds (Bedp1000), doctors (Docp1000), and nurses (Nurp1000) per 1000 individuals in ethnic minority and poverty-stricken counties consistently remained lower than non-minority counties. The growth rates of Bedp1000 in Yi (140%) and other ethnic minority counties (127%) were higher than in non-minority counties (121%), while the growth rates of Docp1000 in Yi (20%) and Zang (11%) counties were lower than non-minority counties (61%). Docp1000 in 33% and 50% of Yi and Zang ethnic counties decreased, respectively. Nurp1000 in Yi (240%) and other ethnic minority (316%) counties increased faster than non-minority counties (198%). The Theil index for beds and nurses declined, while the index for doctors increased. Key factors driving increases in bed allocation include preferential policies and economic development levels, while health practitioner income, economic development levels and geographical environment significantly influence doctor and nurse allocation.

CONCLUSIONS

Preferential policies have been successful in increasing the number of beds in health facilities, but not healthcare workers, in ethnic minority regions. The ethnic disparities in doctor allocation increased in Sichuan Province. To increase the number of doctors and nurses in ethnic minority and poverty-stricken regions, particularly in Yi counties, more preferential policies and resources should be introduced.

The operations of contemporary Han Chinese privilege

This article discusses the conceptual underpinnings and performance of Han Chinese privilege in the People's Republic of China. It suggests that Han Chinese privilege has gained salience from specific public policies and philosophies of governance. This is aptly viewed across a range of sites, including the labour market and media, and involves state institutions and micro-level everyday interactions between the Han Chinese and the ethnic minority populations. Finally, the article theorizes why a robust Han Chinese privilege discourse has not emerged, and remains largely an unacknowledged concept.

Income-related health inequality among rural residents in western China

Objective

Health equality has drawn much public attention in both developed and developing countries. China, the largest developing country, has implemented a new round of health system reform to improve health equality since 2009. This study aims to examine the magnitude and sources of income-related health inequality in western rural regions of China.

Methods

Data were obtained from the Survey of Rural Economic and Social Development in Western China conducted in 2014, in which 14,555 individuals from 5,299 households in 12 provinces were included. Health outcome variables of interest were self-rated health status, prevalence of chronic disease and four-week illness. Concentration index was calculated to assess magnitude of income-related health inequality, and nonlinear decomposition analysis was performed to identify the sources of health inequality.

Results

The Concentration indexes for poor self-rated health status, prevalence of chronic disease and four-week illness were -0.0898 (P<0.001),-0.0860 (P<0.001) and -0.1284 (P<0.001), respectively. Income and education were two main sources of health inequality, accounting for about 25-50% and 15% contribution to the inequality. Ethnicity made <10% contribution to income-related health inequality, and enrollment in New Rural Cooperative Medical Scheme contributed to <1%.

Conclusion

This study found slight income-related health inequality among rural residents in western China, implying that although China has made substantial progress in economic development and poverty alleviation, health inequality in western rural region should still be concerned by the government. To achieve health equality further, the Chinese government should not only strengthen its reimbursement mechanism of the current health insurance scheme to improve affordability of primary healthcare for residents in western rural regions, but also implement health poverty alleviation policies targeting socioeconomically vulnerable population and ethnic minorities in future.

Community perspectives of barriers indigenous women face in accessing maternal health care services in the Chittagong Hill Tracts, Bangladesh

OBJECTIVES

Bangladesh has achieved notable success in improving maternal health by increasing women's access to good quality and low-cost maternal health care (MHC) services. However, the health system of Bangladesh has earned criticism for not ensuring equitable MHC access for all women, particularly for Indigenous women in the Chittagong Hill Tracts (CHT). Little is known about Indigenous communities' perspectives on these inequalities in MHC service access in the CHT. Therefore, this study aimed to explore Indigenous communities' perspectives on challenges and opportunities for improving MHC service access in the CHT.

DESIGN

This qualitative descriptive study was conducted in two sub-districts of Khagrachhari between September 2017 and February 2018. Eight Indigenous key informants from three Indigenous communities (Chakma, Marma and Tripura) were recruited via snowballing and purposive techniques and participated in face-to-face, semi-structured interviews. Key informants comprised community leaders and health care providers. Data were analysed thematically using Nvivo12 software.

RESULTS

Findings suggest that distance, poor availability of resources and infrastructure, lack of community engagement in the design of health interventions, Indigenous cultural beliefs, misconceptions about MHC services, and maltreatment from health care providers were the key barriers to accessing MHC services; all are interconnected. Indigenous women faced humiliation and maltreatment from MHC staff. Failure to provide a culturally-safe environment suggests a lack of cultural competency among health staff, including Indigenous staff.

CONCLUSION

Findings suggest that cultural competency training for all health care providers is needed to improve cultural appropriateness and accessibility of services. Refresher training and undisrupted supply of basic MHC services for front-line care providers will benefit the entire community and will likely be cost-effective for the government. Designing health programmes through extensive community consultation is essential.

Association between ethnicity and health knowledge among the floating population in China

Background

Health equity remains a priority concerns by central government in China. This study aimed to explore ethnic gaps in access to health knowledge categories and sources based on the survey data from a publicly available dataset.

Methods

Data were from 2015 China Migrants Dynamic Survey issued by The National Health Commission in China. Descriptive analyses were performed to reflect geodemographic differences in the floating population of ethnic minority (EMFP) and Han majority (HMFP) with Chi-square test. Ethnic gaps in access to health knowledge categories and sources were explored with Poisson regressions, logistic regressions, and bivariate ordered probit regressions.

Results

In the sample, most of participants had inadequate health information literacy. There were significant differences regarding geodemographic factors between EMFP and HMFP. Illiterate EMFP had likelihood to obtain less health knowledge categories (IRR = 0.80, 95% CI 0.77–0.84) and sources (IRR = 0.83, 95% CI 0.80–0.86) as compared to illiterate HMFP. Most of correlations between health knowledge categories and sources were weak in the samples of EMFP and HMFP.

Conclusion

Ethnic disparities in access to health knowledge categories and sources among the floating population in China were confirmed. Further effective efforts should be provided to reduce ethnic disparities in access to health knowledge under the ethnicity-orientated support of public health resource.

Factors affecting the frequency and contents of routine antenatal care in remote rural China in 2009-2016: an observational study

OBJECTIVE

We assessed factors associated with frequency and contents of antenatal care (ANC) in remote rural China, including province of residence and individual level factors.

DESIGN

Survey-based cross-sectional study.

SETTING

Remote rural China, Five provinces- Jilin, Shaanxi, Hunan, Guizhou, and Ningxia.

SAMPLE

3,918 women with a live birth in 2009-2016.

METHODS

Poisson regression.

MAIN OUTCOME MEASURES

ANC frequency- 5+ visits starting in the first trimester. ANC contents- co-coverage of six care components, and overuse of ultrasound.

MAIN RESULTS

Three quarters (72.9%) of women had 5+ visits starting in the first trimester, 68.8% received all six care components, and 94.5% had 3+ ultrasounds. Only 30.9% women sought ANC from township hospitals, paying between $3.8 and 25.8 per-visit. ANC frequency and contents were associated with women's socio-economic characteristics, but provincial effects were much stronger, even after adjusting for individual factors. Women living in Guizhou and Ningxia, the two poorest provinces with high proportions of ethnic minorities, were particularly underserved. Compared to women in Shaanxi, women in Guizhou were 33% (adjusted RR 0.67, 95%CI 0.61-0.74) less likely to receive 5+ ANC starting in the first trimester; women in Ningxia were 17% less likely (adjusted RR 0.83, 95% CI 0.76-0.90) to receive all six care components.

CONCLUSION

The province of residence was a stronger predictor of ANC frequency and contents than women's individual characteristics in China, suggesting that strengthening the decentralised system of financing and organisation of ANC at province level is crucial to achieving success. Future efforts are warranted to engage sub-regional administrations.

Trends, causes and solutions of maternal mortality in Jinan, China: the epidemiology of the MMR in 1991-2020

BACKGROUND

China was one of the few countries to achieve the Millennium Development Goals 5. China had taken many effective measures to reduce maternal mortality ratio (MMR) and has achieved encouraging progress. These measures were worth sharing for other countries to reduce the MMR, but the introduction of these measures from the national perspective was too grand, and the measures implemented in a city and the results achieved were more valuable. However, there were few studies on the prevalence and trends of prolonged maternal mortality in a city. In this study, we mainly introduced the prevalence of the MMR in Jinan,China from 1991 to 2020, analyzed the causes of trends and put forward some solutions to the difficulty existing in the process of reducing the MMR,hoping to serve as a model for some developing cities to reduce MMR.

METHODS

We collected maternal mortality data from paper records, electronic files and network platforms. The time trend of MMR was tested by Cochran-Armitage Test (CAT). We divided the study period into three stages with 10 years as a stage and the Chi-square test or Fisher's exact test was used to test the difference in MMR of different periods.

RESULTS

From 1991 to 2020, We counted 1,804,162 live births and 323 maternal deaths, and the MMR was 17.93 per 100,000 live births. The MMR declined from 44.06 per 100,000 live births in 1991 to 5.94 per 100,000 live births in 2020, with a total decline of 86.52% and an annual decline of 2.89%. The MMR declined by 88.54% in rural areas, with an average annual decline 2.95%, faster than that in urban areas (82.06, 2.73%). From 1991 to 2020, the top five causes of maternal deaths were obstetric haemorrhage (4.55 per 100,000 live births), amniotic fluid embolism (3.27 per 100,000 live births), pregnancy-induced hypertension (2.61 per 100,000 live births), heart disease (2.33 per 100,000 live births) and other medical complications (2.05 per 100,000 live births). Postpartum hemorrhage, amniotic fluid embolism, pregnancy-induced hypertension showed a downward trend (P < 0.05) and other medical complications showed an upward trend (P < 0.05).

CONCLUSIONS

Subsidy for hospitalized delivery of rural women, free prenatal check-ups for pregnant women and rapid referral system between hospitals have contributed to reducing MMR in Jinan. However, it was still necessary to strengthen the treatment of obstetric hemorrhage by ensuring blood supply, reduce the MMR due to medical complications by improving the skills of obstetricians to deal with medical diseases, and reduce the MMR by strengthening the allocation of emergency equipment in county hospitals and the skills training of doctors.

Prevalence and factors associated with antenatal care service access among Indigenous women in the Chittagong Hill Tracts, Bangladesh: A cross-sectional study

Background

Prevalence of accessing antenatal care (ANC) services among Indigenous women in the Chittagong Hill Tracts (CHT) is unknown. This study aims to estimate the prevalence of accessing ANC services by Indigenous women in the CHT and identify factors associated with knowledge of, and attendance at, ANC services.

Methods

Using a cross-sectional design three Indigenous groups in Khagrachari district, CHT, Bangladesh were surveyed between September 2017 and February 2018. Indigenous women within 36 months of delivery were asked about attending ANC services and the number who attended was used to estimate prevalence. Socio-demographic and obstetric characteristics were used to determine factors associated with knowledge and attendance using multivariable logistic regression techniques adjusted for clustering by village; results are presented as odds ratios (OR), adjusted OR, and 95% confidence intervals (CI).

Results

Of 494 indigenous women who met the inclusion criteria in two upazilas, 438 participated (89% response rate) in the study, 75% were aged 16–29 years. Sixty-nine percent were aware of ANC services and the prevalence of attending ANC services was 53% (n = 232, 95%CI 0.48–0.58). Half (52%; n = 121) attended private facilities. Independent factors associated with knowledge about ANC were age ≥30 years (OR 2.2, 95%CI 1.1–4.6), monthly household income greater than 20,000 Bangladeshi Taka (OR 3.4, 95%CI 1.4–8.6); knowledge of pregnancy-related complications (OR 3.6, 95%CI 1.6–8.1), knowledge about nearest health facilities (OR 4.3, 95%CI 2.1–8.8); and attending secondary school or above (OR 4.8, 95%CI 2.1–11). Independent factors associated with attending ANC services were having prior knowledge of ANC benefits (OR 7.7, 95%CI 3.6–16), Indigenous women residing in Khagrachhari Sadar subdistrict (OR 6.5, 95%CI 1.7–25); and monthly household income of 20,000 Bangladeshi Taka or above (OR 2.8, 95%CI 1.1–7.4).

Conclusion

Approximately half of Indigenous women from Chittagong Hill Tracts Bangladesh attended ANC services at least once. Better awareness and education may improve ANC attendance for Indigenous women. Cultural factors influencing attendance need to be explored.

Barriers to accessing maternal health care services in the Chittagong Hill Tracts, Bangladesh: A qualitative descriptive study of Indigenous women's experiences

BACKGROUND

Increased maternal health care (MHC) service utilisation in Bangladesh over the past decades has contributed to improvements in maternal health outcomes nationally, yet there is little understanding of Indigenous women's experiences of accessing MHC services in Bangladesh.

METHODS

Face-to-face semi-structured qualitative interviews with 21 Indigenous women (aged 15-49 years) within 36 months of delivery from three ethnic groups (Chakma, Marma and Tripura) were conducted between September 2017 and February 2018 in Khagrachhari district. Purposive sampling was used to recruit women representative of the population distribution in terms of age, ethnic community and service use experience. All interviews were conducted in Bangla language and audio-recorded with consent. Interviews were transcribed directly into English before being coded. Data were analysed thematically using a qualitative descriptive approach aided by NVivo12 software.

RESULTS

Of the 21 women interviewed, 14 had accessed at least one MHC service during their last pregnancy or childbirth and were categorised as the User group. The remaining seven participants were categorised as 'Non-users' as they had not access antenatal care, facility delivery or postnatal care services. Women reported that they wanted culturally relevant, respectful, home-based and affordable care, and generally perceived formal MHC services as being only for complications and emergencies. Barriers to accessing MHC services included low levels of understanding about the importance of MHC services, concerns about service costs, limited transport and fears of intrusive practices. Experiences within health services that deterred women from accessing future MHC services included demands for unofficial payments and abusive treatment by public facility staff.

CONCLUSION

Improving access to MHC services for the CHT Indigenous women requires improved understandings of cultural values, priorities and concerns. Multifaceted reform is needed at individual, community and health systems levels to offer culturally appropriate health education and flexible service delivery options.

Prevalence and factors associated with knowledge and access to delivery services at primary health care facilities amongst indigenous women in Khagrachhari district Bangladesh - A cross-sectional study

OBJECTIVE

To estimate the prevalence of facility delivery knowledge and access during childbirth amongst Indigenous women in the Chittagong Hill Tracts, Bangladesh and to identify factors associated with facility delivery service utilisation.

DESIGN

A cross-sectional study design using a structured self-report survey.

SETTING

Two Upazilas (subdistricts) of Kharachhari hill district of the Chittagong Hill Tracts.

PARTICIPANTS

Indigenous women of reproductive age (15-49 years) within 36 months of delivery.

MEASUREMENTS AND FINDINGS

A modified national survey about accessing maternal health services, including delivery services was administered to all Indigenous women that met eligibility, guided by community leaders. Data collected included socio-demographic characteristics and reproductive history. Main outcome variables were the proportion of women having prior knowledge about and access to facility delivery services for childbirth in the three years prior to the survey. Secondary outcomes were sources of information about facility delivery services, decision making about delivery place, and factors associated with knowledge and attendance at facility delivery services. Factors associated with knowledge and attendance were estimated using logistic regression with results reported as adjusted odds ratios and 95% confidence intervals. With an 89% response rate, a total of 438 Indigenous women (220 Chakma, 100 Marma, 118 Tripura) participated in the survey, and 75% were aged 16-29 years. Relatives played a vital role as a source of information about delivery services (59%). Nearly three-quarters (73%) were aware of facility delivery services, however, prevalence of accessing delivery services was 33% (n = 143; 95% CI 0.28-0.37). Relatives were the key decision-makers for accessing facility delivery services (60%). Independent factors associated with knowledge about facility delivery were higher household income (AOR 5.3, 95%CI 2.2-13); having knowledge of nearest health care facilities (AOR 5.8, 95%CI 3.0-11); and attending antenatal care visits during last pregnancy (four or more AOR 3.1, 95% CI 1.3-7.2 and one to three visits AOR 2.7, 95% CI 1.5-5.0). Independent factors associated with accessing facility delivery services at childbirth were attending antenatal care visit; having access to media; higher level of education of partners; and residing at Khagrachhari Sadar compared to Matiranga subdistrict.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Indigenous women in Chittagong Hill Tracts, Bangladesh have sub-optimal knowledge of, and attendance at, facility delivery services for childbirth. Maternal health related interventions should target Indigenous women in order to educate and motivate them to access facility delivery services at childbirth. Rigorous research is needed to explore Indigenous cultural practices related to childbirth that might influence their access to facility delivery services.

Conditional cash transfers, uptake of maternal and child health services, and health outcomes in western rural China

BACKGROUND

Empirical evidence suggests that the uptake of maternal and child health (MCH) services is still low in poor rural areas of China. There is concern that this low uptake may detrimentally affect child health outcomes. Previous studies have not yet identified the exact nature of the impact that a conditional cash transfer (CCT) has on the uptake of MCH services and, ultimately, on child health outcomes. The objective of this study is to examine the relationship between CCT, uptake of MCH services, and health outcomes among children in poor rural areas of western China.

METHODS

We designated two different sets of villages and households that were used as comparisons against which outcomes of the treated households could be assessed. In 2014, we conducted a large-scale survey of 1522 households in 75 villages (including 25 treatment and 50 comparison) from nine nationally designated poverty counties in two provinces of China. In each village, 21 households were selected based on their eligibility status for the CCT program. Difference-in-difference analyses were used to assess the impact of CCT on outcomes in terms of both intention-to-treat (ITT) and average-treatment-effects-on-the-treated (ATT).

RESULTS

Overall, the uptake of MCH services in the sample households were low, especially in terms of postpartum care visits, early breastfeeding, exclusive breastfeeding, and physical examination of the baby. The uptake of the seven types of MCH services in the CCT treatment villages were significantly higher than that in the comparison villages. The results from both the ITT and ATT analyses showed that the CCT program had a positive, although small, impact on the uptake of MCH services and the knowledge of mothers of MCH health issues. Nonetheless, the CCT program had no noticeable effect on child health outcomes.

CONCLUSIONS

The CCT program generated modest improvements in the uptake of MCH services and mothers' knowledge of MCH services in poor rural areas of Western China. These improvements, however, did not translate into substantial improvements in child health outcomes for two potential reasons: poor CCT implementation and the low quality of rural health facilities.

Access to maternal healthcare services among Indigenous women in the Chittagong Hill Tracts, Bangladesh: A cross-sectional study

OBJECTIVES

This study aimed to estimate the prevalence of, and factors associated with, accessing maternal healthcare services (MHC) by Indigenous women in the Chittagong Hill Tracts (CHT), Bangladesh.

DESIGN

This was a cross-sectional survey among Indigenous women of reproductive age.

SETTING

Two upazillas (subdistricts) of Khagrachhari hill district of the CHT.

PARTICIPANTS

Indigenous women (15-49 years) within 36 months of delivery were surveyed about accessing MHC services (antenatal care, delivery and postnatal care) for their last pregnancy and delivery.

PRIMARY OUTCOME MEASURES

The primary outcome for this analysis is the prevalence of accessing any MHC service and secondary outcome is factors associated with access to MHC services for Indigenous women during their last pregnancy and childbirth.

RESULTS

Of 438 Indigenous women (220 Chakma, 100 Marma, 118 Tripura) who participated, 75% were aged 16-30 years. With an 89% response rate, a total of 258 (59%) women reported accessing at least one MHC service (Chakma 51.6%, Marma 28%, Tripura 20.5%; p=<0.001). Independent factors associated with accessing MHC after adjusting for clustering were attending secondary school and above (OR 2.4; 95% CI 1.2 to 4.9); knowledge about nearest health facilities (OR 3.8, 95% CI 1.8 to 7.8) and knowledge of pregnancy-related complications (OR 3.0, 95% CI 1.5 to 5.8).

CONCLUSION

Findings suggest that the prevalence of accessing MHC services is lower among Indigenous women in the CHT compared with national average. MHC access may be improved through better education and awareness raising of local services.

Patterns and determinants of essential neonatal care utilization among underprivileged ethnic groups in Midwest Nepal: a mixed method study

BACKGROUND

Globally in 2017 neonatal death accounted for 46% of under-five deaths. Nepal is among the developing countries which has a high number of neonatal deaths. The rates are high among poor socio-economic groups, marginalized, as well as people living in remote areas of Nepal. This paper, thus tries to examine the utilization pattern and maternal, household, and health service factors affecting underprivileged ethnic groups in Midwest Nepal.

METHODS

A cross-sectional mixed method study was conducted from September 2017 to April 2018 in Bardiya district. Quantitative data were collected from a household survey of women who gave live births within the last 12 months prior to data collection (n = 362). Interviews were also undertaken with 10 purposively selected key informants. Logistic regression model was used to determine the factors associated with essential neonatal care utilization. Thematic analysis was undertaken on the qualitative data.

RESULTS

Overall, neonatal care utilization was 58.6% (53.3-63.7%), with big variations seen in the coverage of selected neonatal care components. Factors such as birth order (2.059, 1.13-3.75), ethnicity (2.28, 1.33-3.91), religion (2.37, 1.03-5.46), perceived quality of maternal and neonatal services (2.66, 1.61-4.39) and awareness on immediate essential newborn cares (2.22, 1.28-3.87) were identified as the determining factors of neonatal care utilization.

CONCLUSIONS

The coverage of birth preparedness and complication readiness, adequate breastfeeding, and postnatal care attendance were very low as compared to the national target for each component. The determinants of essential neonatal care existed at maternal, household as well as health facility level and included ethnicity, religion, perceived quality of maternal and neonatal services, birth order and awareness on immediate essential newborn care. Appropriate birth spacing, improving the quality of maternal and neonatal services at health facilities and raising mother's level of awareness about neonatal care practices are recommended.

Uptake of maternal care and childhood immunization among ethnic minority and Han populations in Sichuan province: a study based on the 2003, 2008 and 2013 health service surveys

Background

China has made remarkable progress in maternal and child health (MCH) over the last thirty years, but socio-economic inequalities persist. Ethnicity has become an important determinant of poor MCH outcomes, but little rigorous analytical work has been done in this area. To understand the socio-economic factors that explain ethnic variation in uptake of MCH care, we report the findings from an analysis in Sichuan province.

Methods

We linked data from the 2003, 2008 and 2013 National Health Service Surveys in Sichuan Province. The ethnic disparities in uptake of maternal care (completing 5 antenatal visits, giving birth in hospital and receiving a caesarean section) and childhood immunization (Bacillus Calmette Guerin (BCG), three doses of diphtheria (DPT) and measles immunization) were examined by geographical (Han district/county vs. ethnic minority county) and individual-based (Han women/children vs. ethnic minority women/children) comparisons. We also examined variation by distance to township and county hospitals, women’s education, parity and age using weighted multilevel Poisson regressions with random intercept at district/county level.

Results

Ethnic inequalities in maternal care were marked, both at the geographical (district/county) and the individual level. The % of births in hospital was 90.7% among women in Han districts, compared to 83.3% among women living in Han counties (crude RR 0.93; 95% CI 0.75–1.15), 53.8% among Han women living in ethnic minority counties (crude RR 0.57; 95% CI 0.36–0.93), and 13.5% among ethnic minority women living in ethnic minority counties (crude RR 0.18; 95% CI 0.06–0.57). Adjusting the analysis for survey year, education, parity and distance to county level hospital weakened the association between geographical/individual ethnicity and uptake of maternity care, but associations remained remarkably strong. Coverage of childhood immunization was much higher than uptake of maternity care, and inequalities by ethnicity were much less pronounced.

Conclusion

Lessons can be learned from China’s successful immunization programme to further reduce inequalities in access to maternity care among ethnic minority populations in remote areas. Bringing the services closer to the women’s homes and strengthening health promotion from the township to the village level may encourage more women to seek antenatal care and give birth in hospital.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2371-y) contains supplementary material, which is available to authorized users.

The influence of basic public health service project on maternal health services: an interrupted time series study

Background

Reducing maternal mortality remains a global priority. In 2000, the United Nations Member States pledged to work towards a series of Millennium Development Goals (MDGs), in which the fifth target was to reduce maternal mortality ratio by 75% from 1990 to 2015. The Chinese government introduced Basic Public Health Service project in 2009 to the further improvement of maternal health services and reduction in maternal mortality. China had achieved the goal of MDG5 1 year ahead of the schedule in 2014, but the effects of the project on reducing maternal mortality were rarely evaluated with robust methods.

Methods

We conducted a longitudinal study on maternal mortality ratio by extracting mortality data from the National Maternal Mortality Surveillance System (1991–2016) and maternal health services measures from the China health statistic yearbook (2001–2016). We utilized the segmented linear regression model to assess changes and trends of maternal mortality ratio and maternal health services before and after the introduction of Basic Public Health Service project. Pearson correlation analysis was conducted to measure the strength of association between the maternal mortality ratio and maternal health services.

Results

The yearly trend change of national maternal mortality ratio was − 1.76 (p < 0.01) after the introduction of Basic Public Health Service project in 2009, while the yearly trend change of maternal health record establish rate, prenatal examination rate, postpartum visit rate was 0.77 (p < 0.01), 0.61 (p < 0.01) and 0.83 (p < 0.01) separately. The negative correlations were also found between national maternal mortality ratio and prenatal examination rate (r = − 0.95, p < 0.01), maternal health record establish rate (r = − 0.93, p < 0.01) and postpartum visit rate (r = − 0.92, p < 0.01).

Conclusions

The Basic Public Health Service project was found to be associated with the improvements in the maternal health services and reduction in maternal mortality. The design and implementation of the project may serve as a positive example for other developing countries. Continued monitoring and assessment of project effects should be stressed.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7207-1) contains supplementary material, which is available to authorized users.

Primary health care among rural pregnant women in China: achievements and challenges in maternal mortality ratio

Background:

The maternal mortality ratio (MMR) is not only an important indicator of maternal and infant safety, but also a sign of the development of economy, education, and medical care in a country. In the last 60 years, the Chinese government has implemented various strategies and policies to reduce the MMR, especially in the rural areas.

Aim:

This study aimed to discuss the strategies developed by the Chinese government, showing the successful experience of Chinese intervention programs and highlighting the challenges to the government in the context of current economic and social status.

Method:

This study probed into the Chinese government’s efforts and achievements in the MMR reducing by reviewing the relevant health policies, extracting the data from China Health Statistics Yearbook of 2015, analyzing the reduction of maternal death in rural areas and the major causes from 1991 to 2015, comparing the MMR trend in urban and rural areas, and discussing the changes of the situation in China.

Finding:

Although it seems that Chinese government’s efforts have brought evangel to the rural pregnant women and significantly reduced rural maternal mortality, the government still needs to develop more equitable and flexible primary health care policies to narrow the imbalance in health resource allocation and pay more attention to the health care for the rural-to-urban migration in China.

Barriers to accessing maternal healthcare among ethnic minority women in Western China: a qualitative evidence synthesis

Quantitative evidence suggests that ethnic disparities in maternal healthcare use are substantial in Western China, but the reasons for these remain under-researched. We undertook a systematic review of English and Chinese databases between January 1, 1990 and February 23, 2018 to synthesize qualitative evidence on barriers faced by ethnic minority women in accessing maternal healthcare in Western China. Four English and 6 Chinese language studies across 8 provinces of Western China and 13 ethnic minority groups were included. We adapted the 'Three Delays' framework and used thematic synthesis to categorize findings into six themes. Studies reported that ethnic minority women commonly held traditional beliefs and had lower levels of education, which limited their willingness to use maternal health services. Despite the existence of different financial protection schemes for services related to delivery care, hospital birth was still too costly for some rural households, and some women faced difficulties navigating reimbursement procedures. Women who lived remotely were less likely to go to hospital in advance of labour because of difficulties in arranging accommodation; they often only sought care if pregnancies were complicated. Poor quality of care in health facilities, particularly misunderstandings between doctors and patients due to language barriers or differences in socio-economic status, and clinical practices that conflicted with local fears and traditional customs, were reported. The overall evidence is weak however: authors treated different ethnicities as if they belonged to one homogeneous group and half of the studies failed in methodological rigour. The current evidence base is very limited and poor in quality, so much more research elucidating the nature of 'ethnicity' as a set of barriers to maternal healthcare access is needed. Addressing the multiple barriers associated with ethnicity will require multi-faceted solutions that adequately reflect the specific local context.

Use of maternal health services among women in the ethnic rural areas of western China

BACKGROUND

The use of maternal health services can markedly promote the maternal health and safety, but there has been a low utilization rate in the ethnic rural areas of western China. Furthermore, the correlated factors have not been well studied. This study aims to assess factors related to the use of maternal health services among women in these areas.

METHODS

A cross-sectional study of 68 villages in China's western Sichuan province was conducted in September 2014. All qualifying women from each sample village were involved. A structured questionnaire was administrated in households through face-to-face interviews by trained enumerators to obtain information of use of maternal health services and related factors. Structural equation modeling (SEM) was used to evaluate the direct and indirect relationships between use of maternal health services and correlated factors.

RESULTS

A total of 760 women from 68 villages were enrolled. The proportion of antenatal care (ANC), hospital delivery and postpartum visits were 68.94, 48.29 and 28.42% respectively. The SEM analysis demonstrated that social economic status (SES) (β= - 0.75, β< 0.01), ANC (β=0.13, β< 0.01), and time from home to the nearest hospital (β= - 0.09, β< 0.05), were positively correlated to hospital delivery and postpartum care visits, while maternal care knowledge and perceived quality of hospital care did not have direct correlation. For ANC, SES (β= - 0.36, β< 0.01), time from home to the nearest hospital (β= - 0.13, β< 0.05), knowledge on maternal care (β=0.12, β< 0.01) and perceived quality of hospital care (β=0.10, β< 0.01) were all directly correlated factors. Treating ANC as an intermediate variable showed the indirect relationship that perceived quality of hospital care (β=0.01, β< 0.01) and maternal care knowledge (β=0.02, β< 0.01) had with hospital delivery and postpartum care rates.

CONCLUSIONS

Use of maternal health services is low among women in ethnic rural areas. ANC has important direct and intermediate effects on subsequent use of hospital delivery and postpartum care. Improving ANC behavior should be a priority of maternal health care reforms. Given the long travel times for these women, reforms must also prioritize breaking down practical barriers that prevent this population from accessing care.

Indigenous women's access to maternal healthcare services in lower- and middle-income countries: a systematic integrative review

OBJECTIVES

Globally, Indigenous people have lower-health status compared to non-Indigenous people due to unequal access to health care. Barriers or enablers to accessing maternal health services by Indigenous women are not well researched. This review aims to determine accessibility and utilisation of maternal primary healthcare services among Indigenous women in lower- and middle-income countries.

METHODS

We conducted a systematic integrative review of published and grey literature published between 2000 and 2017. Studies on maternal healthcare service utilisation by Indigenous women in lower- and middle-income countries were included. From 3092 articles identified, 10 met the eligibility criteria.

RESULTS

The most prominent barrier to accessing maternal primary healthcare services was the top-down nature of intervention programmes, which made programmes culturally unfriendly for Indigenous women. Distance, cost, transport, accommodation, language barriers and lack of knowledge about existing services also impacted access.

CONCLUSIONS

Findings provided insights into understanding the gaps in existing policies for Indigenous women and their access to maternal health services. Results suggested that efforts be made to ensure appropriate programmes for Indigenous women's maternal health right.

Inequalities in maternal health care utilization in Benin: a population based cross-sectional study

BACKGROUND

Ensuring equitable access to maternal health care including antenatal, delivery, postnatal services and fertility control methods, is one of the most critical challenges for public health sector. There are significant disparities in maternal health care indicators across many geographical locations, maternal, economic, socio-demographic factors in many countries in sub-Sahara Africa. In this study, we comparatively explored the utilization level of maternal health care, and examined disparities in the determinants of major maternal health outcomes.

METHODS

This paper used data from two rounds of Benin Demographic and Health Survey (BDHS) to examine the utilization and disparities in factors of maternal health care indicators using logistic regression models. Participants were 17,794 and 16,599 women aged between15-49 years in 2006 and 2012 respectively. Women's characteristics were reported in percentage, mean and standard deviation.

RESULTS

Mean (±SD) age of the participants was 29.0 (±9.0) in both surveys. The percentage of at least 4 ANC visits was approximately 61% without any change between the two rounds of surveys, facility based delivery was 93.5% in 2012, with 4.9% increase from 2006; postnatal care was currently 18.4% and contraceptive use was estimated below one-fifth. The results of multivariable logistic regression models showed disparities in maternal health care service utilization, including antenatal care, facility-based delivery, postnatal care and contraceptive use across selected maternal factors. The current BHDS showed age, region, religion were significantly associated with maternal health care services. Educated women, those from households of high wealth index and women currently working were more likely to utilize maternal health care services, compared to women with no formal education, from poorest households or not currently employed. Women who watch television (TV) were 1.31 (OR = 1.31; 95% CI = 1.13-1.52), 1.69 (OR = 1.69; 95% CI = 1.20-2.37) and 1.38 (OR = 1.38; 95% CI = 1.16-1.65) times as likely to utilize maternal health care services after adjusting for other covariates.

CONCLUSION

The findings would guide stakeholders to address inequalities in maternal health care services. More so, health care programmes and policies should be strengthened to enhance accessibility as well as improve the utilization of maternal care services, especially for the disadvantaged, uneducated and those who live in hard-to-reach rural areas in Benin. The Benin government needs to create strategies that cover both the supply and demand side factors at attain the universal health coverage.

Is outpatient care benefit distribution of government healthcare subsidies equitable in rural ethnic minority areas of China? Results from cross-sectional studies in 2010 and 2013

OBJECTIVES

Government healthcare subsidies for healthcare facilities play a significant role in providing more extensive healthcare access to patients, especially poor ones. However, equitable distribution of these subsidies continues to pose a challenge in rural ethnic minority areas of China. This study aimed to evaluate the benefits distribution of outpatient services across different socioeconomic populations in China's rural ethnic minority areas.

SETTING

Inner Mongolia Autonomous Region, Xinjiang Autonomous Region and Qinghai Province.

DESIGN

Two rounds of cross-sectional study.

PARTICIPANTS

One thousand and seventy patients in 2010 and 907 patients in 2013, who sought outpatient services prior to completing the household surveys, were interviewed.

METHODS

Benefits incidence analysis was performed to measure the benefits distribution of government healthcare subsidies across socioeconomic groups. The concentration index (CI) for outpatient care at different healthcare facility levels in rural ethnic minority areas was calculated. Two rounds of household surveys using multistage stratified samples were conducted.

FINDINGS

The overall CI for outpatient care was -0.0146 (P>0.05) in 2010 and -0.0992 (P<0.01) in 2013. In 2010, the CI was -0.0537 (P<0.01), -0.0085 (P>0.05) and -0.0034 (P>0.05) at levels of village clinics (VCs), township health centres (THCs) and county hospitals (CHs), respectively. In 2013, the CI was -0.1353 (P<0.05), -0.0695 (P>0.05) and -0.1633 (P<0.01) at the levels of VCs, THCs and CHs, respectively.

CONCLUSION

Implementation of the gatekeeper mechanism helped improve the benefits distribution of government healthcare subsidies in rural Chinese ethnic minority areas. Equitable distribution of government healthcare subsidies for VCs was improved by increasing financial input and ensuring the performance of primary healthcare facilities. Equitable distribution of subsidies for CHs was improved by policies that rationally guided patients' care-seeking behaviour. In addition, highly qualified physicians were also a key factor in ensuring equitable benefits distribution.

Do experiences and perceptions about quality of care differ among social groups in Nepal? : A study of maternal healthcare experiences of women with and without disabilities, and Dalit and non-Dalit women

BACKGROUND

Suboptimal quality of care and disparities in services by healthcare providers are often reported in Nepal. Experience and perceptions about quality of care may differ according to women's socio-cultural background, individual characteristics, their exposure and expectations. This study aimed to compare perceptions of the quality of maternal healthcare services between two groups that are consistently considered vulnerable, women with disabilities from both the non-Dalit population and Dalit population and their peers without disabilities from both non-Dalit and Dalit communities.

METHODS

A cross-sectional survey was conducted among 343 total women that included women with disabilities, Dalits and non-Dalits. Women were recruited for interview, who were aged 15-49 years, had been pregnant within the last five years and who had used maternal care services in one of the public health facilities of Rupandehi district. A 20-item, Likert-type scale with four sub-scales or dimensions: 'Health Facility', 'Healthcare Delivery', 'Inter-personal' and 'Access to Care' was used to measure women's perceptions of quality of care. Chi-square test and t test were used to compare groups and to assess differences in perceptions; and linear regression was applied to assess confounding effects of socio-demographic factors. The mean score was compared for each item and separately for each dimension.

RESULTS

All groups, women with disabilities and women without disabilities, Dalit and non-Dalit rated their perceptions and experiences of quality of care lowly in a number of items. While perceived quality of care between women with disabilities and without disabilities in the 'Health Facility' dimension and associated items, was found to differ (p<0.05), this difference was linked to disability status, but was not linked to caste differences. For example, differences in mean scores relating to 'Cleanliness and Facilities', 'Open and Friendliness' and 'Compassion and Kindness' were highly significant (p<0.001), with women with disabilities rating these as better than women without disabilities. On the other hand, women without disabilities rated the 'Availability of cash Incentives' more highly (p<0.01). No significant differences were found between Dalit and non-Dalit women in perceived quality of care, except in relation to 'Cleanliness and facilities', which Dalit women rated lower than non-Dalits (p<0.05).

CONCLUSIONS

Perceptions about the quality of care differed significantly by disability status but not by caste. All groups rated the quality of healthcare delivery, interpersonal and personal factors as well as access to services 'low.' Poor service user experiences and perceptions of quality of care undermine opportunities to translate increased healthcare coverage into improved access and outcomes. Greater attention is required by policy makers, health planners and providers to the improvement of quality of care in health facilities.

Interventions to provide culturally-appropriate maternity care services: factors affecting implementation

Background

The World Health Organization recently made a recommendation supporting ‘culturally-appropriate’ maternity care services to improve maternal and newborn health. This recommendation results, in part, from a systematic review we conducted, which showed that interventions to provide culturally-appropriate maternity care have largely improved women’s use of skilled maternity care. Factors relating to the implementation of these interventions can have implications for their success. This paper examines stakeholders’ perspectives and experiences of these interventions, and facilitators and barriers to implementation; and concludes with how they relate to the effects of the interventions on care-seeking outcomes.

Methods

We based our analysis on 15 papers included in the systematic review. To extract, collate and organise data on the context and conditions from each paper, we adapted the SURE (Supporting the Use of Research Evidence) framework that lists categories of factors that could influence implementation. We considered information from the background and discussion sections of papers included in the systematic review, as well as cost data and qualitative data when included.

Results

Women’s and other stakeholders’ perspectives on the interventions were generally positive. Four key themes emerged in our analysis of facilitators and barriers to implementation. Firstly, interventions must consider broader economic, geographical and social factors that affect ethnic minority groups’ access to services, alongside providing culturally-appropriate care. Secondly, community participation is important in understanding problems with existing services and potential solutions from the community perspective, and in the development and implementation of interventions. Thirdly, respectful, person-centred care should be at the core of these interventions. Finally, cohesiveness is essential between the culturally-appropriate service and other health care providers encountered by women and their families along the continuum of care through pregnancy until after birth.

Conclusion

Several important factors should be considered and addressed when implementing interventions to provide culturally-appropriate care. These factors reflect more general goals on the international agenda of improving access to skilled maternity care; providing high-quality, respectful care; and community participation.

Progress and challenges in maternal health in western China: a Countdown to 2015 national case study

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 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.

FUNDING

Government of Canada, UNICEF, and the Bill & Melinda Gates Foundation.

Effectiveness of interventions to provide culturally appropriate maternity care in increasing uptake of skilled maternity care: a systematic review

Addressing cultural factors that affect uptake of skilled maternity care is recognized as an important step in improving maternal and newborn health. This article describes a systematic review to examine the evidence available on the effects of interventions to provide culturally appropriate maternity care on the use of skilled maternity care during pregnancy, for birth or in the postpartum period. Items published in English, French and/or Spanish between 1 January 1990 and 31 March 2014 were considered. Fifteen studies describing a range of interventions met the inclusion criteria. Data were extracted on population and intervention characteristics; study design; definitions and data for relevant outcomes; and the contexts and conditions in which interventions occurred. Because most of the included studies focus on antenatal care outcomes, evidence of impact is particularly limited for care seeking for birth and after birth. Evidence in this review is clustered within a small number of countries, and evidence from low- and middle-income countries is notably lacking. Interventions largely had positive effects on uptake of skilled maternity care. Cultural factors are often not the sole factor affecting populations' use of maternity care services. Broader social, economic, geographical and political factors interacted with cultural factors to affect targeted populations' access to services in included studies. Programmes and policies should seek to establish an enabling environment and support respectful dialogue with communities to improve use of skilled maternity care. Whilst issues of culture are being recognized by programmes and researchers as being important, interventions that explicitly incorporate issues of culture are rarely evaluated.

Utilization of services provided by village based ethnic minority midwives in mountainous villages of Vietnam

Introduction

Since 2011, the Vietnam’s Ministry of Health implemented the ethnic minority midwives (EMMs) scheme in order to increase the utilization of maternal health services by women from ethnic minorities and those living in hard-to-reach mountainous areas. This paper analyzes the utilization of antenatal, delivery, and postpartum care provided by EMMs and reports the key determinants of utilization of EMM services as perceived by service users.

Methods

A structured questionnaire was administered in 2015 to all mothers (n=320) who gave birth to a live-born during a 1-year period in 31 villages which had EMM in two provinces, Dien Bien and Kon Tum. A multivariate logistic regression model was used to examine the association between all potential factors and the use of services provided by EMMs.

Results

We found that EMMs provided more antenatal care and postnatal care as compared with delivery services, which corresponded to their job descriptions. The results also showed that utilization of antenatal care provided by EMMs was lower than that of postnatal care. The proportion of those who never heard about EMM was high (24%). Among the mothers who knew about EMM services, 33.4% had antenatal checkups, 20.1% were attended during home deliveries, and 57.3% had postnatal visits by an EMM. Key factors that determined the use of EMM services included knowledge of the location of EMM’s house, being aware about EMMs by health workers, trust in services provided by EMMs, and perception that many others mothers in a village also knew about EMM services.

Conclusion

EMM seems to be an important mechanism to ensure assistance during home births and postnatal care for ethnic minority groups, who are often resistant to attend health facilities. Building trust and engaging with communities are the key facilitators to increase the utilization of services provided by EMMs. Communication campaigns to raise awareness about EMMs and to promote their services in the village, particularly by other health workers, represent an important strategy to further improve effectiveness of EMM scheme.

Barriers to Hospital Deliveries among Ethnic Minority Women with Religious Beliefs in China: A Descriptive Study Using Interviews and Survey Data

Background: China has made great progress in improving hospital delivery-the coverage of hospital delivery has increased to above 95% in most regions- some regions lag behind owing to geographic and economic inequality, particularly the poor ethnic minority areas of the Sichuan Province. This study explores factors which may influence hospital delivery from multiple perspectives, with implications for practice and policy. Methods: A framework analysis approach was used to identify and categorize the main barriers and levers to hospital delivery. Our analysis draws on basic information from the sampled counties (Butuo and Daofu). Results: The hospital delivery rate was below 50% in the two sampled areas. In both areas, the “New Rural Cooperative Medical Scheme” and “Rural hospital delivery subsidy” were introduced, but only Butuo county had a transportation subsidy policy. Socioeconomically disadvantaged women in both counties who delivered their babies in hospitals could also apply for financial assistance. A lack of transport was among the main reasons for low hospital delivery rates in these two counties. Furthermore, while the hospital delivery costs could be mostly covered by “New Rural Cooperative Medical Scheme” or “Rural Hospital Delivery Subsidy”, reimbursement was not guaranteed. People in Daofu county might be affected by their Buddhism religion for hospital delivery. Women in Butuo following the Animism religion would refuse delivery in hospitals because of language barriers. Traditional lay beliefs were the main factor that influenced hospital delivery; their understandings of reproductive health varied, and many believed that childbirth should not be watched by strangers and that a home delivery was safe. Conclusions: This study has highlighted a number of barriers and levers to hospital delivery in rural poor ethnic minority areas which could inform and improve the access and rate of hospital delivery rate; thereby reducing health inequalities in maternal and child health in China.

Reducing high maternal mortality rates in western China: a novel approach

Among the Millennium Development Goals, maternal mortality reduction has proven especially difficult to achieve. Unlike many countries, China is on track to meeting these goals on a national level, through a programme of institutionalizing deliveries. Nonetheless, in rural, disadvantaged, and ethnically diverse areas of western China, maternal mortality rates remain high. To reduce maternal mortality in western China, we developed and implemented a three-level approach as part of a collaboration between a regional university, a non-profit organization, and local health authorities. Through formative research, we identified seven barriers to hospital delivery in a rural Tibetan county of Qinghai Province: (1) difficulty in travel to hospitals; (2) hospitals lack accommodation for accompanying families; (3) the cost of hospital delivery; (4) language and cultural barriers; (5) little confidence in western medicine; (6) discrepancy in views of childbirth; and (7) few trained community birth attendants. We implemented a three-level intervention: (a) an innovative Tibetan birth centre, (b) a community midwife programme, and (c) peer education of women. The programme appears to be reaching a broad cross-section of rural women. Multilevel, locally-tailored approaches may be essential to reduce maternal mortality in rural areas of western China and other countries with substantial regional, socioeconomic, and ethnic diversity.

Measuring and decomposing the inequality of maternal health services utilization in western rural China

BACKGROUND

To measure socioeconomic inequalities in maternal health services in rural western China and to analyze the determinants' contributions of inequalities.

STUDY DESIGN

a cross-sectional study.

METHODS

The data utilized in this study were obtained from a cross-sectional study from 10 provinces in rural Western China in 2005. Wealth index of household socioeconomic status was developed by using principle component analysis. Concentration index, concentration curve and decomposition of the concentration index were employed to measure socioeconomic inequality in maternal health services utilization.

RESULTS

For more than four times prenatal visits, the concentration index was 0.0605 (95% CI: 0.0603, 0.0607). The concentration index of hospital delivery was 0.0230 (95% CI: 0.0210, 0.0240) and the concentration index of more than 2 times postnatal visits was 0.0842 (95% CI: 0.0836, 0.0847). Han ethnicity woman, particularly in conjunction with high school education and rich wealth status, was the main contributor to inequality in maternal health services utilization.

CONCLUSIONS

There is a strong pro-rich inequality of maternal health services in rural western China. This study suggests that an effective way to reduce the inequality is not only to narrow the gap of income between the rich and poor, but focus education on ethnic minority woman in rural remote areas.

Progress on the maternal mortality ratio reduction in Wuhan, China in 2001-2012

BACKGROUND

Most maternal deaths occur in developing countries and most maternal deaths are avoidable. China has made a great effort to reduce MMR by three quarters to meet the fifth Millennium Development Goal (MDG5).

METHODS

This retrospective study reviewed and analyzed maternal death data in Wuhan from 2001 to 2012. Joinpoint regression and multivariate Poisson regression was conducted using the log-linear model to measure the association of the number of maternal deaths with time, cause of death, where the death occurred, and cognitive factors including knowledge, attitude, resource, and management stratified.

RESULTS

The MMR declined from 33.41 per 100,000 live births in 2001 to 10.63 per 100,000 live births in 2012, with a total decline of 68.18% and an average annual decline of 9.89%. From 2001-2012, the four major causes of maternal death were obstetric hemorrhage (35.16%), pregnancy complications (28.57%), amniotic fluid embolism (16.48%) and gestational hypertension (8.79%). Multivariate Poisson regression showed on average the MMR decreased by.17% each year from 2001-2006 and stayed stagnant since 2007-2012.

CONCLUSIONS

With the reduction in MMR in obstetric death (e.g. obstetric hemorrhage), there had been a remarkable reduction in MMR in Wuhan in 2001-2012, which may be due to (1) the improvement in the obstetric quality of perinatal care service on prevention and treatment of obstetric hemorrhage and emergency care skills, and (2) the improvement in the maternal health management and quality of prenatal care. Interventions to further reduce the MMR include several efforts such as the following: (1) designing community-based interventions, (2) providing subsidies to rural women and/hospitals for hospital delivery, (3) screening for pregnancy complications, and (4) establishing an emergency rescue system for critically ill pregnant women.

How to Undertake Research of MHC Utilization in Under-developed Countries? A Case Study of MHC Utilization in Central and Western Rural China

OBJECTIVE

This study was undertaken to address practical problems in maternal health care (MHC) utilization and conduct in-depth study of maternal health services utilization in underdeveloped countries(regions), thus to contribute to the achieving of the UN Millennium Development Goal 5.

DATA COLLECTION

After searching and screening based on key words like "MHC" and "utilization", we included 45 English articles and 106 Chinese articles from Pubmed, Medline, China Knowledge Resource Integrated and Wang Fang data base. The research themes, issues, designs, perspectives, dimensions and methods of these dissertations were analyzed.

RESULTS

The development of MHC utilization research can be divided into three phases: Studies of the first phase focused primarily on decreasing MMR, which caused attention to the central and western rural areas maternal health services in China from domestic as well as international community; Studies of the second phase centered around the practical impacts of the implementation of MHC relevant programs and policy, confirming that the implementation of these programs and policies improved MHC service delivery and utilization, and promoted cooperation between researchers and practitioners; Studies of the third phase focused on the quality of MHC service utilization. We also found that the major problem in the current MHC service utilization is the huge gap across regions and the existing researches lack innovation and comparison researches between in different countries.

CONCLUSION

Research themes of MHC services change regularly. We should grasp the characteristics and defects of current research to increase the innovation of future research and to better response to the problem solving, and thus to provide more valuable reference for the policy and practice of underdeveloped countries and areas.

Childbirth traditions and cultural perceptions of safety in Nepal: critical spaces to ensure the survival of mothers and newborns in remote mountain villages

OBJECTIVE

to uncover local beliefs regarding pregnancy and birth in remote mountainous villages of Nepal in order to understand the factors which impact on women's experiences of pregnancy and childbirth and the related interplay of tradition, spiritual beliefs, risk and safety which impact on those experiences.

DESIGN

this study used a qualitative methodological approach with in-depth interviews framework within social constructionist and feminist critical theories.

SETTING

the setting comprised two remote Nepalese mountain villages where women have high rates of illiteracy, poverty, disadvantage, maternal and newborn mortality, and low life expectancy. Interviews were conducted between February and June, 2010.

PARTICIPANTS

twenty five pregnant/postnatal women, five husbands, five mothers-in-law, one father-in-law, five service providers and five community stakeholders from the local communities were involved.

FINDINGS

Nepalese women, their families and most of their community strongly value their childbirth traditions and associated spiritual beliefs and they profoundly shape women's views of safety and risk during pregnancy and childbirth, influencing how birth and new motherhood fit into daily life. These intense culturally-based views of childbirth safety and risk conflict starkly with the medical view of childbirth safety and risk.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

if maternity services are to improve maternal and neonatal survival rates in Nepal, maternity care providers must genuinely partner with local women inclusive of their cultural beliefs, and provide locally based primary maternity care. Women will then be more likely to attend maternity care services, and benefit from feeling culturally safe and culturally respected within their spiritual traditions of birth supported by the reduction of risk provided by informed and reverent medicalised care.

Disadvantaged populations in maternal health in China who and why?

BACKGROUND

China has made impressive progress towards the Millennium Development Goal (MDG) for maternal and reproductive health, but ensuring that progress reaches all segments of the population remains a challenge for policy makers. The aim of this review is to map disadvantaged populations in terms of maternal health in China, and to explain the causes of these inequities to promote policy action.

METHODS

We searched PUBMED, Popline, Proquest and WanFang and included primary studies conducted in mainland China. Experts were also contacted to identify additional studies. Disadvantaged populations in terms of MDG 5 and the reasons for this disadvantage explored by authors were identified and coded based on the conceptual framework developed by the WHO Commission on the Social Determinants of Health.

RESULTS

In China, differences in maternal health service utilization and the maternal mortality ratio among different income groups, and among regions with different socio-economic development still exist, although these differences are narrowing. Groups with low levels of education and ethnic minorities utilize maternal health care less frequently and experience higher maternal mortality, although we could not determine whether these differences have changed in the last decade. Rural-to-urban migrants use maternal health care and contraception to a lower extent than permanent residents of cities, and differential maternal mortality shows a widening trend among these groups. Gender inequity also contributes to the disadvantaged position of women. Intermediary factors that explain these inequities include material circumstances such as long distances to health facilities for women living in remote areas, behavioral factors such as traditional beliefs that result in reduced care seeking among ethnic minorities, and health system determinants such as out-of-pocket payments posing financial barriers for the poor.

CONCLUSIONS

Inequity in maternal health continues to be an issue worthy of greater programmatic and monitoring efforts in China.

Unintended Consequences of Policy Decisions to Reduce Maternal Mortality in the Asia Pacific

OBJECTIVES:To describe the role of midwives and maternity care in three low resource settings and to challenge some policy options introduced to reduce maternal mortality for women residing in rural and remote areas.

APPROACH:A series of retrospective analyses were undertaken drawing on work the authors have conducted in rural and remote China, Timor-Leste, and Samoa over the past 5–20 years. Sources include our own empirical research, grey literature, as well as published secondary sources.

FINDINGS:In China, hospital birthing is promoted as a major strategy in reducing maternal mortality. This has greatly increased financial burdens for women and their families. In Samoa, traditional birth attendants (TBAs) are integrated into Samoa’s health system alongside midwives and other health professionals, and they play a critical role in providing support for pregnant and birthing women. In Timor-Leste, the government has moved away from training TBAs and has shifted the focus from skilled attendance to facility-based delivery. Evaluation of a national maternity waiting home strategy, designed to improve access to facility-based delivery, did not improve access for women in remote areas.

CONCLUSIONS:Low-income countries need to be cautious when adopting global solutions, such as facility-based delivery, to tackle maternal deaths. Women-centered and cost-effective care should be provided locally. Culturally compatible maternity care can be achieved in concert with safety and emergency obstetric care. Midwives can create the bridges between social and professional systems that allow this to happen.

China's facility-based birth strategy and neonatal mortality: a population-based epidemiological study

BACKGROUND

China's success in improving the quality of and access to obstetric care in hospitals offers an opportunity to examine the effect of a large-scale facility-based strategy on neonatal mortality. We aimed to establish this effect by assessing how the institutional strategy of intrapartum care has affected neonatal mortality and its regional inequalities.

METHODS

We did a population-based epidemiological study of China's National Maternal and Child Mortality Surveillance System from 1996 to 2008. We used data from 116 surveillance sites in China (37 urban districts and 79 rural counties) to examine neonatal mortality by cause, socioeconomic region, and place of birth, with Poisson regression to calculate relative risks. Rural counties were categorised into types 1-4, with type 4 being the least developed. We report attributable risks and preventable fractions for hospital births versus home births.

FINDINGS

Neonatal mortality decreased by 62% between 1996 and 2008. The rate of neonatal mortality was much lower for hospital births than for home births in all regions, with relative risks (RR) ranging from 0·30 (95% CI 0·22-0·40) in type 2 rural counties, to 0·52 (0·33-0·83) in type 4 counties (p<0·0001). The proportion of neonatal deaths prevented by hospital birth ranged from 70% (95% CI 59·7-77·8) to 48% (16·9-67·3). Babies born in urban hospitals had a low rate of neonatal mortality (5·7 per 1000 livebirths); but those born in hospitals in type 4 rural counties were almost four times more likely to die than were children born in urban hospitals (RR 3·80, 2·53-5·72).

INTERPRETATION

Other countries can learn from China's substantial progress in reducing neonatal mortality. The major effect of China's facility-based strategy on neonatal mortality is much greater than that reported for community-based interventions. Our findings will provide a great impetus for countries to increase demand for and quality of facility-based intrapartum care.

FUNDING

China Medical Board, UNICEF China.

Compliance with referral for curative care in rural Burkina Faso

BACKGROUND

The goal of this study is to contribute to improving the functioning of the referral system in rural Burkina Faso. The main objective is to ascertain the compliance rate for referral and to identify the factors associated with successful referral.

METHODS

A record review of 12 months of curative consultations in eight randomly selected health centres was conducted to identify referral cases. To assess referral compliance, all patient documents at referral hospitals from the day of the referral up to 7 days later were checked to verify whether the referred case arrived or not. Descriptive statistics were then used to compute the compliance rate. Hierarchical modelling was performed to identify patient and provider factors associated with referral compliance.

RESULTS

The number of visits per person per year was 0.6 and the referral rate was 2.0%. The compliance rate was 41.5% (364/878). After adjustment, females (OR = 0.71; 95% CI = 0.52-0.98), patients referred during the rainy seasons (OR = 0.56; 95% CI = 0.40-0.78), non-emergency referrals (OR = 0.47; 95% CI = 0.34-0.65) and referrals without a referral slip (OR = 0.30; 95% CI = 0.21-0.43) were significantly less likely to comply. Children between 5 and 14 years old (OR = 0.61; 95% CI = 0.35-1.06) were at a higher risk of non-compliance, but the difference did not reach statistical significance. Moreover, none of provider characteristics was statistically significantly associated with non-compliance. CONCLUSIONS In a rural district of Burkina Faso, we found a relatively low compliance with referral after the official referral system was organized in 2006. Patient characteristics were significantly associated with a failure to comply. Interventions addressing female patients' concerns, increasing referral compliance in non-emergency situations, reducing inconvenience and opportunity costs due to seasonal/climate factors, and assuring the issue of a referral slip when a referral is prescribed may effectively improve referral compliance.

Barriers to increasing hospital birth rates in rural Shanxi Province, China

This study investigated the reasons for continued high rates of home births in rural Shanxi Province, northern China, despite a national programme designed to encourage hospital deliveries. We conducted semi-structured interviews with 30 home-birthing women in five rural counties and drew on hospital audit data, observations and interviews with local health workers from a larger study. Multiple barriers were identified, including economic and geographic factors and poor quality of maternity care. Women's main reasons for not having institutional births were financial difficulties (n=26); poor quality of antenatal care (n=13); transport problems (n=11); dissatisfaction with hospital care expressed as fear of being in hospital (n=10); convenience of being at home and continuity of care provided by traditional birth attendants (TBAs) (n=10); and belief that the birth would be normal (n=6). These barriers must all be overcome to improve access to and acceptability of hospital birth. To ensure that the national policy of improving the hospital birth rate is implemented effectively, the government needs to improve the quality of antenatal and delivery care, increase financial subsidies to reduce out-of-pocket payments, remove transport barriers, and where hospital birth is not available in remote areas, consider allowing skilled attendance at home on an outreach basis and integrate TBAs into the health system.

Socioeconomic inequalities in hospital births in China between 1988 and 2008

OBJECTIVE

To assess trends in hospital births in China during 1988-2008 in an effort to determine if efforts to overcome financial barriers to giving birth in hospital have reduced the access gap between the rich and the poor.

METHODS

Cross-sectional data obtained from four National Health Service Surveys were used to determine trends in hospital births during 1988-2008. Crude and adjusted annual rates were calculated by means of Poisson regression and were used to define trends across socioeconomic regions and households in different income quintiles.

FINDINGS

In 2008 women throughout China were giving birth in hospital almost universally except in region IV, the most remote rural region, where the percentage of hospital births was only 60.8. Hospital births in this region had increased steadily before 2002, but after that year the upward trend slowed down. During 1988-2001 the average yearly increase had been 21%, but in 2002-2008 it dropped to 10% (P = 0.0031). Inequalities between socioeconomic regions were greater than among individual households belonging to different income strata. By 2008 the difference between low- and high-income households in the proportion of hospital births had become very small (96.1% and 87.7% of high- and low-income households, respectively, gave birth in hospital that year).

CONCLUSION

Most Chinese women now give birth in hospital, but the poorest rural region is still lagging behind. A more active and comprehensive approach will be needed to increase hospital births in these remote, hard-to-reach populations.

Utilisation, contents and costs of prenatal care under a rural health insurance (New Co-operative Medical System) in rural China: lessons from implementation

Background

In China, the New Co-operative Medical System (NCMS), a rural health insurance system, has expanded nationwide since 2003. This study aims to describe prenatal care use, content and costs of care in one county where prenatal care is included in the NCMS and two counties where it is not. It also explores the perceptions of stakeholders of the prenatal care benefit package in order to understand the strengths and weaknesses of the approach in the context of rural China and to draw lessons from early implementation.

Methods

This study is based on the data from a cross-sectional survey and a qualitative investigation conducted in 2009. A survey recruited women giving birth in 2008, including 544 women in RC County (which covered prenatal care) and 619, and 1071 in other two counties (which did not). The qualitative investigation in RC included focus group discussions with women giving birth before or after 2007, individual interviews with local policy makers and health managers, NCMS managers and obstetric doctors in township hospitals.

Results

There were no significant differences in prenatal care use between RC County (which covered prenatal care) and other two counties (which did not): over 70% of women started prenatal visits early and over 60% had five or more visits. In the three counties: a small proportion of women received the number of haemoglobin and urine tests recommended by the national guideline; 90% of women received more ultrasound tests than recommended; and the out-of-pocket expenditure for prenatal care consumed a high proportion of women's annual income in the low income group. In RC: only 20% of NCMS members claimed the reimbursement; the qualitative study found that the reimbursement for prenatal care was not well understood by women and had little influence on women's decisions to make prenatal visits; and several women indicated that doctors suggested them taking more expensive tests.

Conclusions

Whether or not prenatal care was included in the NCMS, prenatal care use was high, but the contents of care were not provided following the national guideline and more expensive tests were recommended by doctors. Costs were substantial for the poor.