Reducing maternal mortality in China in the era of the two-child policy

Inpatient autopsy rate and associated factors in a Chinese megacity: a population-based retrospective cohort study

OBJECTIVES

This study investigated the autopsy rate of hospital deaths in Shenzhen megacity and identified factors that may impact the decision to perform an autopsy in hospital deaths.

DESIGN

This is a population-based retrospective cohort study.

SETTING

Shenzhen is a megacity in China with a population of more than 17 million and a total of 151 hospitals. The official dataset of the inpatient medical record home page was used. Demographic, clinical and hospital information was extracted.

PARTICIPANTS

All the 35 272 inpatient deaths between 2016 and 2022 with known autopsy status were included to calculate the overall autopsy rate. Among them, a total of 34 577 cases with complete data, classified hospital and Chinese nationality, were included for further multivariable rare events logistic regression and Poisson pseudo maximum likelihood regression.

OUTCOME MEASURES

Whether the inpatient death was autopsied or not.

RESULTS

The autopsy procedure was performed in 0.9% (319/35 272) of hospital deaths. The autopsy decision was significantly and positively associated with being married (OR= 1.60, 95% CI: 1.16 to 2.21), self-paying (OR=1.56, 95% CI: 1.07 to 2.26), death due to external causes of injury and poisoning (OR=1.69, 95% CI: 1.02 to 2.81) and pregnancy (OR=13.58, 95% CI: 4.94 to 37.36), but negatively associated with age (OR=0.97, 95% CI: 0.96 to 0.98), emergency admission (OR=0.66, 95% CI: 0.49 to 0.88), referral (OR=0.47, 95% CI: 0.25 to 0.88), neoplasms (OR=0.35, 95% CI: 0.22 to 0.56), respiratory diseases (OR=0.49, 95% CI: 0.26 to 0.95) and for-profit hospitals (OR=0.45, 95% CI: 0.23 to 0.91). There were no statistically significant differences in autopsy rates between large teaching hospitals and other hospitals.

CONCLUSIONS

The autopsy rate of hospital deaths was extremely low, largely due to healthcare providers. Even large teaching hospitals do not request more autopsies compared with other hospitals, after controlling for the patient characteristics. More efforts are urged to encourage hospitals and healthcare providers to proactively request autopsies, helping to revive this important procedure.

Differentiated thyroid cancer and adverse pregnancy outcomes: a propensity score-matched retrospective cohort study

Background

Differentiated thyroid cancer (DTC) has been increasingly common in women of reproductive age. However, the evidence remains mixed regarding the association of DTC with adverse pregnancy outcomes in pregnant women previously diagnosed with DTC.

Methods

We conducted a retrospective cohort study in the Peking University Third Hospital in Beijing, China between January 2012 and December 2022. We included singleton-pregnancy women with a pre-pregnancy DTC managed by surgical treatment (after-surgery DTC) or active surveillance (under-surveillance DTC). To reduce the confounding effects, we adopted a propensity score to match the after-surgery and under-surveillance DTC groups with the non-DTC group, respectively, on age, parity, gravidity, pre-pregnancy weight, height, and Hashimoto's thyroiditis. We used conditional logistics regressions, separately for the after-surgery and under-surveillance DTC groups, to estimate the adjusted associations of DTC with both the composite of adverse pregnancy outcomes and the specific mother-, neonate-, and placenta-related pregnancy outcomes.

Results

After the propensity-score matching, the DTC and non-DTC groups were comparable in the measured confounders. In the after-surgery DTC group (n = 204), the risk of the composite or specific adverse pregnancy outcomes was not significantly different from that of the matched, non-DTC groups (n = 816; P > 0.05), and the results showed no evidence of difference across different maternal thyroid dysfunctions, gestational thyrotropin levels, and other pre-specified subgroup variables. We observed broadly similar results in the under-surveillance DTC group (n = 37), except that the risk of preterm birth, preeclampsia, and delivering the low-birth-weight births was higher than that of the matched, non-DTC group [n = 148; OR (95% CI): 4.79 (1.31, 17.59); 4.00 (1.16, 13.82); 6.67 (1.59, 27.90)].

Conclusions

DTC was not associated with adverse pregnancy outcomes in pregnant women previously treated for DTC. However, more evidence is urgently needed for pregnant women with under-surveillance DTC, which finding will be clinically significant in individualizing prenatal care.

The possible impact of the universal two-child policy on pregnancy outcomes

PURPOSE

The implementation of the universal two-child policy contributes to adverse pregnancy outcomes, but how the policy change leads to adverse pregnancy outcomes is not well elaborated. In this study, we aimed to compare maternal characteristics and complications, accessed the change in the proportion of maternal characteristics and maternal complications, and evaluated the mediation of maternal characteristics on maternal complications.

METHODS

Demographic and clinical data of three-level sample facilities were extracted from China's National Maternity Near Miss Obstetrics Surveillance System from Jan 1, 2012 to May 31, 2021. The associations between the universal two-child policy and maternal risk factors, the universal two-child policy and maternal complications, and maternal risk factors and maternal complications were evaluated using multivariate logistic regression analyses, with odds ratios (ORs) and 95% confidence intervals (CIs). Mediation analysis was used to estimate the potential mediation effects on the associations between the policy and maternal complications. Population-attributable fractions (PAF) were conducted to quantify the maternal complications burden attributable to the implementation of the universal two-child policy.

RESULTS

In the context of the universal two-child policy, the incidence of maternal near miss, antepartum or intrapartum complication, and post-partum complication increased at municipal- and county-level sample facilities. After adjusting for covariables, there were significant associations between the universal two-child policy and maternal risk factors (P < 0.001), the universal two-child policy and an increased risk of maternal complications (P < 0.001), and maternal risk factors and maternal complications(P < 0.001). The effects of the universal two-child policy on maternal near miss and medical disease were significantly mediated by maternal risk factors with mediation proportions of 19.77% and 4.07% at the municipal-level sample facility, and mediation proportions for 2.72% at the county-level sample facility on medical disease. The universal two-child policy contributed 19.34%, 5.82%, 8.29%, and 46.19% in the incidence of the maternal near miss, antepartum or intrapartum complication, post-partum complication, and medical disease at municipal-level sample facility, respectively. The corresponding PAF% at county-level sample facility was 40.49% for maternal near miss, 32.39% for the antepartum or intrapartum complication, 61.44% for post-partum complication, and 77.72% for medical disease. For provincial-level sample facility, the incidence of maternal near miss, antepartum or intrapartum complications, and medical diseases decreased (P < 0.05) and no statistically significant difference occurred in the incidence of post-partum complications.

CONCLUSIONS

In the context of the universal two-child policy, the incidence of maternal near miss, antepartum or intrapartum complication, and post-partum complication increased at municipal- and county-level sample facility. Maternal risk factors may play a mediating role in the effect of policy change and maternal complications. Provincial hospitals have been able to improve the quality of perinatal health care and reduce adverse pregnancy outcomes by adjusting their obstetric service strategies in the context of the new birth policy.

Burden of multiple high-risk factors in pregnancy before and after the universal two-child policy in Chinese women: An observational study

Background

The prevalence of high-risk pregnancy increased after the implementation of two-child policy in China, but the impact of this policy change on the burden and profile of multiple high-risk factors in pregnancy (MHFP) has been insufficiently explored. We hypothesised that the profile of MHFP might have changed after the two-child policy was implemented and aimed to estimate the prevalence, intercorrelation, and outcomes of MHFP before and after its introduction.

Methods

We obtained data on the population of pregnant women before (2015) and after (2020/2021) the implementation of universal two-child policy in Huai'an. We then included 33 risk factors in our analysis based on the Five-Colour Management framework and defined MHFP as an individual having two or more of these factors. We also estimated the changes of the prevalence of each single factor and their coexistence. Lastly, we performed a network analysis to assess the intercorrelations across these factors and used logistic regression models to evaluate MHFP-related pregnancy outcomes.

Results

We observed an increase in the prevalence of MHFP after the implementation of the universal two-child policy (25.8% in 2015 vs 38.4% in 2020/2021, P < 0.01). Chronic conditions (e.g. gestational diabetes mellitus, abnormal body mass index) had the largest increase among the included factors, while cardiovascular disease and hypertensive disorders were central factors of the network structures. The correlations of advanced maternal age with abnormal pregnancy histories and scarred uteri increased significantly from 2015 to 2020/2021. MHFP was associated with multiple pregnancy outcomes, including preterm birth (adjusted odds ratio (aOR) = 2.57; 95% confidence interval (CI) = 2.39-2.75), low birthweight (aOR = 2.77; 95% CI = 2.54-3.02), low Apgar score (aOR = 1.41; 95% CI = 1.19-1.67), perinatal death (aOR = 1.75; 95% CI = 1.44-2.12), and neonatal death (aOR = 1.76; 95% CI = 1.42-2.18). Moreover, an increasing number and certain combinations of MHFP were associated with higher odds of pregnancy outcomes. For example, the aOR of preterm birth increased from 1.67 (95% CI = 1.52-1.87) for one risk factor to 8.03 (95% CI = 6.99-9.22) for ≥4 risk factors.

Conclusions

Chinese women experienced a higher burden of multiple high-risk factors after the introduction of the two-child policy, particularly those with advanced maternal age, obesity, and chronic conditions. Strategies targeting chronic conditions for women with MHFP should be prioritised and a shift to a multiple-factor-oriented framework is needed in the expanding Chinese maternal health care system.

Status of the midwifery workforce and childbirth services and the impact of midwife staffing on birth outcomes in China: a multicentre cross-sectional study

OBJECTIVE

To investigate the status of the midwifery workforce and childbirth services in China and to identify the association between midwife staffing and childbirth outcomes.

DESIGN

A descriptive, multicentre cross-sectional survey.

SETTING

Maternity hospitals from the eastern, central and western regions of China.

PARTICIPANTS

Stratified sampling of maternity hospitals between 1 July and 31 December 2021.The sample hospitals received a package of questionnaires, and the head midwives from the participating hospitals were invited to fill in the questionnaires.

RESULTS

A total of 180 hospitals were selected and investigated, staffed with 4159 midwives, 412 obstetric nurses and 1007 obstetricians at the labour and delivery units. The average efficiency index of annual midwifery services was 272 deliveries per midwife. In the sample hospitals, 44.9% of women had a caesarean delivery and 21.4% had an episiotomy. Improved midwife staffing was associated with reduced rates of instrumental vaginal delivery (adjusted β -0.032, 95% CI -0.115 to -0.012, p<0.05) and episiotomy (adjusted β -0.171, 95% CI -0.190 to -0.056, p<0.001).

CONCLUSION

The rates of childbirth interventions including the overall caesarean section in China and the episiotomy rate, especially in the central region, remain relatively high. Improved midwife staffing was associated with reduced rates of instrumental vaginal delivery and episiotomy, indicating that further investments in the midwifery workforce could produce better childbirth outcomes.

Fertility policy changes, maternal and foetal characteristics and birth timing patterns at a tertiary referral centre in Beijing: a ten-year retrospective study

OBJECTIVE

This study aimed to explore the impacts of the changing national fertility policy on maternal and fetal characteristics, and birth timing patterns and provide a basis for the management of the obstetric and midwifery workforce.

DESIGN

Retrospective cohort study.

SETTING

Data from medical register of a tertiary referral centre in Beijing, China.

PARTICIPANTS

We included 20 334 births with a gestational age more than 28 weeks during January 2013-September 2023.

MAIN OUTCOMES

The main outcomes included birth numbers, maternal age, parity, birth modes, premature rates, neonatal birth weight, and birth timings.

RESULTS

The birth rates showed a general rising trend before 2016. Afterwards, the birth rates kept decreasing and reached the bottom level in 2022. The caesarean section rates showed a declining trend, while the assisted birth rates were progressively rising, especially among primiparous women. From 2013 to 2022, the proportions of multiparous women (increasing from 9.3% to 36.6%) and women with advanced maternal age (increasing from 11.4% to 34.5%) were on the rise, together with increasing rates of premature birth (increasing from 5.7% to 8.5%) and neonatal low birth weight (rising from 4.3% to 7.2%) in this population. This study found a significant peak of births between 14:00 and 15:00, which remained unchanged despite shifts in the fertility policy (p<0.001 and [Formula: see text] values close to 1, respectively).

CONCLUSION

The 'three-child' policy did not boost the birth rate further 2 years later after its enactment, and the proportion of multiparous women and women with advanced maternal age were on the rise, accompanied by an increase in rates of premature birth and low birth weight. Targeted training should be offered to healthcare professionals to empower them to deal with possible negative pregnancy outcomes and childbirth complications. Prepregnancy and antepartum education should be parity specific. Adequate midwifery staffing during this 14:00-15:00 is vital to promote a safe birth.

Development and psychometric testing of a Chinese version of the postnatal care experience scale for postpartum women

BACKGROUND

Postnatal period is a critical transitional phase in the lives of mothers and newborn babies. In recent years the importance on promoting a positive experience of care following childbirth is increasingly emphasized. Yet published evidence of the methodological and psychometric quality of instruments to evaluate women's experience of comprehensive postnatal care is still lacking.

OBJECTIVE

This study aimed to develop and validate a unique scale (the Chinese version of the Postnatal Care Experience Scale, PCES) to measure women's overall experience of care during postnatal periods.

METHODS

The PCES instrument was developed and validated over three phases, including item development, scale development, and scale evaluation. The item pool of the PCES was generated through existing literature and in-depth semi-structured interviews, followed by assessment of content validity and rating of importance and feasibility of items through two-round Delphi surveys. Psychometric properties were examined in a convenience sample of 736 postpartum women. Both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were conducted to assess the construct validity of the developed PCES. The relationship between the total PCES score and the global item construct was estimated using Pearson product-moment coefficient. Reliability was assessed using Cronbach's alpha and Spearman Brown coefficients.

RESULTS

The content validity index of the Chinese version PCES was 0.867. Following item reduction analysis, this instrument consisted of 30 five-point Likert items. The Kaiser-Meyer-Olkin statistic was 0.964 and the chi-square value of the Bartlett spherical test was 11665.399 (P < .001). The scale explained 75.797% of the total variance and consisted of three subscales, including self-management, social support, and facility- and community-based care. The Pearson correlation coefficient between the total PCES score and the global item construct was 0.909. The CFA showed that the 3-factor model had suitable fitness for the data. Cronbach's alpha value and Spearman-Brown Split-half reliability for the total scale were 0.979 and 0.941, respectively.

CONCLUSIONS

The newly developed 30-item PCES is a psychometrically reliable and valid instrument that assesses women's overall experience of postnatal care. Future research should aim to use the PCES in various populations to obtain further evidence for its validity and reliability.

Trends, influencing factors and prediction analysis of under-five and maternal mortality rates in China from 1991 to 2020

Introduction

Under-five mortality rate (U5MR) and maternal mortality rate (MMR) are important indicators for evaluating the quality of perinatal health and child health services in a country or region, and are research priorities for promoting maternal and infant safety and maternal and child health. This paper aimed to analysis and predict the trends of U5MR and MMR in China, to explore the impact of social health services and economic factors on U5MR and MMR, and to provide a basis for relevant departments to formulate relevant policies and measures.

Methods

The JoinPoint regression model was established to conduct time trend analysis and describe the trend of neonatal mortality rate (NMR), infant mortality rate (IMR), U5MR and MMR in China from 1991 to 2020. The linear mixed effect model was used to assess the fixed effects of maternal health care services and socioeconomic factors on U5MR and MMR were explored, with year as a random effect to minimize the effect of collinearity. Auto regressive integrated moving average models (ARIMA) were built to predict U5MR and MMR from 2021 to 2025.

Results

The NMR, IMR, U5MR and MMR from 1991 to 2020 in China among national, urban and rural areas showed continuous downward trends. The NMR, IMR, U5MR and MMR were significantly negatively correlated with gross domestic product (GDP), the proportion of the total health expenditure (THE) to GDP, system management rate, prenatal care rate, post-natal visit rate and hospital delivery rate. The predicted values of national U5MR from 2021 to 2025 were 7.3 ‰, 7.2 ‰, 7.1 ‰, 7.1 ‰ and 7.2 ‰ and the predicted values of national MMR were 13.8/100000, 12.1/100000, 10.6/100000, 9.6/100000 and 8.3/100000.

Conclusion

China has made great achievements in reducing the U5MR and MMR. It is necessary for achieving the goals of Healthy China 2030 by promoting the equalization of basic public health services and further optimizing the allocation of government health resources. China's experience in reducing U5MR and MMR can be used as a reference for developing countries to realize the SDGs.

Prevalence and Trends of Birth Defects - Five Counties, Shanxi Province, China, 2003-2022

What is already known about this topic?

The Shanxi Province, located in northern China, holds the highest prevalence of birth defects (BDs) across the country. Following the implementation of a nationwide folic acid supplementation program in 2009, a significant reduction of 53.89% in the prevalence of neural tube defects (NTDs) was observed in Shanxi from 2012 to 2017. However, despite this decrease, the prevalence rate for congenital heart defects (CHDs) in 2017 was over four times that of the 2012 rate. Since 2014, CHDs have emerged as the most predominant BD in Shanxi.

What is added by this report?

The present study has identified a marked reduction in the prevalence of both total BDs and NTDs in five counties within Shanxi over the past two decades. As of 2017-2022, NTDs continue to be the most prevalent BDs recorded in this region. Contrarily, there has been a noteworthy increase in the prevalence of CHDs, ranking them among the top five most common BDs in the region between 2017 and 2022, though their rate remains below the national average. Additionally, the proportion of external anomalies remains high. Nevertheless, due to constrained access to primary healthcare services and diagnostic facilities, the early detection rate for internal anomalies, particularly CHDs, may be underestimated in the region.

What are the implications for public health practice?

The results of this study underscore the necessity for augmented efforts in promoting folic acid supplementation as a preventive measure for NTDs. Moreover, improvements in the distribution of medical resources within this region are recommended, particularly the introduction and enforcement of local training programs aimed at enhancing CHD screening and diagnostic processes in these respective counties.

The choice of delivery place in Indonesia: Does home residential status matter?

Background

To care for their health needs, women in Indonesia who live with their parents or in-laws frequently lose their independence, including the choice of delivery place.

Aim

The study aimed to analyze the effect of home residential status on the choice of delivery place in Indonesia.

Methods

The study design was a cross-sectional study. The study employed secondary data from 2017 Indonesian Demographic and Health Survey (IDHS). The research included 15,357 women aged 15-49 with live births in the last five years. Meanwhile, the study used place of delivery as an outcome variable and home residential status as an exposure variable. Moreover, the research employed nine control variables: type of residence, age group, education level, employment status, marital status, parity, wealth status, health insurance, and antenatal care visits-the final analysis using binary logistic regression.

Findings

The result shows that women with home residential status in the alone category were 1.248 times more likely than those in the joint category to choose to give birth to healthcare facilities (AOR 1.248; 95% CI 1.143-1.361). In addition to home residential status, the study also found seven control variables to have a relationship with the choice of place of delivery. The seven control variables were the type of residence, age group, education level, parity, wealth status, health insurance, and antenatal care.

Conclusion

The study concluded that home residential status affects the choice of delivery place in Indonesia.

Correlation of abnormal brain changes with perinatal factors in very preterm infants based on diffusion tensor imaging

Background

It remains unclear whether very preterm (VP) infants have the same level of brain structure and function as full-term (FT) infants. In addition, the relationship between potential differences in brain white matter microstructure and network connectivity and specific perinatal factors has not been well characterized.

Objective

This study aimed to investigate the existence of potential differences in brain white matter microstructure and network connectivity between VP and FT infants at term-equivalent age (TEA) and examine the potential association of these differences with perinatal factors.

Methods

A total of 83 infants were prospectively selected for this study: 43 VP infants (gestational age, or GA: 27–32 weeks) and 40 FT infants (GA: 37–44 weeks). All infants at TEA underwent both conventional magnetic resonance imaging (MRI) and diffusion tensor imaging (DTI). Significant differences in white matter fractional anisotropy (FA) and mean diffusivity (MD) images between the VP and FT groups were observed using tract-based spatial statistics (TBSS). The fibers were tracked between each pair of regions in the individual space, using the automated anatomical labeling (AAL) atlas. Then, a structural brain network was constructed, where the connection between each pair of nodes was defined by the number of fibers. Network-based statistics (NBS) were used to examine differences in brain network connectivity between the VP and FT groups. Additionally, multivariate linear regression was conducted to investigate potential correlations between fiber bundle numbers and network metrics (global efficiency, local efficiency, and small-worldness) and perinatal factors.

Results

Significant differences in FA were observed between the VP and FT groups in several regions. These differences were found to be significantly associated with perinatal factors such as bronchopulmonary dysplasia (BPD), activity, pulse, grimace, appearance, respiratory (APGAR) score, gestational hypertension, and infection. Significant differences in network connectivity were observed between the VP and FT groups. Linear regression results showed significant correlations between maternal years of education, weight, the APGAR score, GA at birth, and network metrics in the VP group.

Conclusions

The findings of this study shed light on the influence of perinatal factors on brain development in VP infants. These results may serve as a basis for clinical intervention and treatment to improve the outcome of preterm infants.

The Impact of COVID-19 on Maternal Mental Health during Pregnancy: A Comparison between Canada and China within the CONCEPTION Cohort

The effect of the COVID-19 pandemic on maternal mental health has been described in Canada and China but no study has compared the two countries using the same standardized and validated instruments. In this study, we aimed to evaluate and compare the impact of COVID-19 public health policies on maternal mental health between Canada and China, as we hypothesize that geographical factors and different COVID-19 policies are likely to influence maternal mental health. Pregnant persons >18 years old were recruited in Canada and China using a web-based strategy. All participants recruited between 26 June 2020 and 16 February 2021 were analyzed. Self-reported data included sociodemographic variables, COVID-19 experience and maternal mental health assessments (Edinburgh Perinatal Depression Scale (EPDS), Generalized Anxiety Disorders (GAD-7) scale, stress and satisfaction with life). Analyses were stratified by recruitment cohort, namely: Canada 1 (26 June 2020-10 October 2020), Canada 2 and China (11 October 2020-16 February 2021). Overall, 2423 participants were recruited, with 1804 participants within Canada 1, 135 within Canada 2 and 484 in China. The mean EDPS scores were 8.1 (SD, 5.1) in Canada 1, 8.1 (SD, 5.2) in Canada 2 and 7.7 (SD, 4.9) in China (p-value Canada 2/China: p = 0.005). The mean GAD-7 scores were 2.6 (SD, 2.9) in China, 4.3 (SD, 3.8) in Canada 1 (p < 0.001) and 5.8 (SD, 5.2) in Canada 2 (p < 0.001). When adjusting for stress and anxiety, being part of the Chinese cohort significantly increased the chances of having maternal depression by over threefold (adjusted OR 3.20, 95%CI 1.77-5.78). Canadian and Chinese participants reported depressive scores nearly double those of other crises and non-pandemic periods. Lockdowns and reopening periods have an important impact on levels of depression and anxiety among pregnant persons.

Non-Isolated Neural Tube Defects with Comorbid Malformations Are Responsive to Population-Level Folic Acid Supplementation in Northern China

Simple Summary

Neural tube defects are severe congenital malformations of the central nervous system. Some cases also have comorbid malformations in other organ systems, which cause morbidity and mortality in affected individuals. Although folic acid is effective in preventing neural tube defects, whether folic acid prevents those cases which have comorbid malformations, or only isolated neural tube defects is unknown. In this study, we described the epidemiology of neural tube defects with comorbid malformations and assessed the impact of folic acid supplementation. We found the prevalence of neural tube defects with comorbid malformations decreased after population-level folic acid supplementation in northern China. Malformations of various organ systems are more common in people with neural tube defects, suggesting common etiology. For fetuses with NTDs, clinicians are also suggested to consider screening for possible comorbid congenital malformations.

Abstract

Objective: Comorbid congenital malformation of multiple organs may indicate a shared genetic/teratogenic causality. Folic acid supplementation reduces the population-level prevalence of isolated neural tube defects (NTDs), but whether complex cases involving independent malformations are also responsive is unknown. We aimed to describe the epidemiology of NTDs with comorbid malformations in a Chinese population and assess the impact of folic acid supplementation. Study Design: Data from five counties in Northern China were obtained between 2002 and 2021 through a population-based birth defects surveillance system. All live births, stillbirths, and terminations because of NTDs at any gestational age were recorded. NTDs were classified as spina bifida, anencephaly, or encephalocele. Isolated NTDs included spina bifida cases with presumed secondary malformations (hydrocephalus, hip dislocation, talipes). Non-isolated NTDs were those with independent concomitant malformations. Results: A total of 296,306 births and 2031 cases of NTDs were recorded from 2002–2021. A total of 4.8% of NTDs (97/2031) had comorbid defects, which primarily affected the abdominal wall (25/97), musculoskeletal system (24/97), central nervous system (22/97), and face (15/97). The relative risk of cleft lip and/or palate, limb reduction defects, hip dislocation, gastroschisis, omphalocele, hydrocephalus, and urogenital system defects was significantly greater in infants with NTDs than in the general population. Population-level folic acid supplementation significantly reduced the prevalence of both isolated and non-isolated NTDs. Conclusion: Epidemiologically, non-isolated NTDs follow similar trends as isolated cases and are responsive to primary prevention by folic acid supplementation. Various clinically-important congenital malformations are over-represented in individuals with NTDs, suggesting a common etiology.

Trends in the disease burden of congenital heart disease in China over the past three decades

OBJECTIVE

To investigate the disease burden of congenital heart disease (CHD) in China from 1990 to 2019.

METHODS

Using the data from Global Burden of Disease (GBD) study 2019, the incidence, age-standardized incidence rates, the mortality, age-standardized mortality rates, disability-adjusted life year (DALY) and age-standardized DALY rates of CHD were calculated. Time trend analysis of disease burden-related indicators was analyzed by Joinpoint regression model. Age-period-cohort model was used to describe age, period, and birth cohort effects in CHD mortality population. The relationship between age-standardized incidence, mortality, DALY rates of congenital heart disease and human development index (HDI) were analyzed by Pearson correlation.

RESULTS

From 1990 to 2019, the mean annual percentage change (AAPC) in age-standardized incidence rate, mortality rate and DALY rate of CHD in China were -0.1%(95% CI: -0.7%-0.4%)、-3.5%(95% CI: -3.7%--3.2%) and -3.5%(95% CI: -3.7%--3.2%), respectively. CHD usually occurred in the first year of life. The mean incidence rate at birth was 2497.9/100 000, and the mean incidence rate under 1 year of age was 2626.6/100 000. During the period of 1995-2000, the incidence rate in newborn and <1 year children showed an exponential upward trend, then it remained a steady downward trend. However, there was an exponential increase in <1 year children during 2010-2013 and 2014-2015, followed by an exponential decrease to the lowest value in the last three decades. The mortality of CHD tended to decrease with age, with mortality of 101.67/100 000 for children under 5 years of age and a decrease after 5 years of age. However, there was a transient increase in mortality in age group 55-<60. From 1995 to 2019, the relative risk of death of patients with CHD showed a downward trend. Compared with 1995-1999, the rate ratio of death decreased by 24% in 2015-2019. Such downward trend was also observed in the birth cohort after 1945. Compared with the 1945-1949 birth cohort, the rate ratio of death for patients with CHD decreased by 75% in the 2015-2019 birth cohort. When HDI<0.58 (before 1999), the age-standardized incidence of CHD was positively correlated with HDI ( r=0.74, P<0.05). When HDI≥0.58 (after 1999), the age-standardized incidence of CHD was negatively correlated with HDI ( r=-0.76, P<0.01). The age-standardized mortality and DALY rates were negatively correlated with HDI ( r=-0.95 and -0.93, both P<0.01).

CONCLUSIONS

During 1990 to 1999, the incidence of CHD increases and is positively correlated with the social development. During 1999 to 2019, the incidence of CHD decreases and is negatively correlated with the social development. The disease burden of CHD decreases and is negatively correlated with the social development. Some progress has been made in the field of prevention and control of CHD, but the disease burden remains high among younger population in China.

Cohort profile: the Taicang and Wuqiang mother-child cohort study (TAWS) in China

PURPOSE

The Taicang and Wuqiang cohort study (TAWS) was established to examine the association between early-life nutrition and children's health, and to explore the potential roles of maternal health, metabolites and microbiota in children's health in two different regions of China.

PARTICIPANTS

A total of 7041 mother-child pairs were recruited during early pregnancy (n=4035, 57.3%) or delivery phase (n=3006, 42.7%) from health centres or hospitals in Taicang and Wuqiang. Mother-child pairs were followed up three times during pregnancy, once during delivery, and 7-10 times in the 3 years after delivery. Questionnaires were used to collect data on diet, supplementary intake, physical activity, depression scale, disease occurrence, feeding practice and development quotient of children. Anthropometric measurements of mothers and their children were assessed at each visit. Pregnancy outcomes were extracted from medical records. Biospecimens were collected and stored, including venous blood, cord blood, urine, stool, breast milk, cord and placenta.

FINDINGS TO DATE

Data from the TAWS cohort showed different baseline characteristics of participants at the two sites of TAWS. Abnormal metabolism occurred among newborns whose mothers were diagnosed with gestational diabetes mellitus. Maternal serum folic acid above 14.5 ng/mL at early pregnancy was associated with a reduced risk of delivering small-for-gestational-age newborns.

FUTURE PLANS

The association between maternal nutrition and the health of offspring will be examined at various follow-up visits. Biomarkers will be analysed to assess the associations between early-life nutrition and child development, immunity and health. Strategic recommendations for optimal infant feeding practices, obesity prevention and routine healthcare items will be developed and proposed based on the findings from the study. Children in this prospective cohort study will be followed up once a year until age 12 years to further examine the relationships between early-life nutrition and children's long-term development and health.

Severe maternal morbidity: admission shift from intensive care unit to obstetric high-dependency unit

Background

To study temporal trends of intensive care unit (ICU) admission in obstetric population after the introduction of obstetric high-dependency unit (HDU).

Methods

This is a retrospective study of consecutive obstetric patients admitted to the ICU/HDU in a provincial referral center in China from January 2014 to December 2019. The collected information included maternal demographic characteristics, indications for ICU and HDU admission, the length of ICU stay, the total length of in-hospital stay and APACHE II score. Chi-square and ANOVA tests were used to determine statistical significance. The temporal changes were assessed with chi-square test for linear trend.

Results

A total of 40,412 women delivered and 447 (1.11%) women were admitted to ICU in this 6-year period. The rate of ICU admission peaked at 1.59% in 2016 and then dropped to 0.67% in 2019 with the introduction of obstetric HDU. The average APACHE II score increased significantly from 6.8 to 12.3 (P < 0.001) and the average length of ICU stay increased from 1.7 to 7.1 days (P < 0.001). The main indications for maternal ICU admissions were hypertensive disorders in pregnancy (39.8%), cardiac diseases (24.8%), and other medical disorders (21.5%); while the most common reasons for referring to HDU were hypertensive disorders of pregnancy (46.5%) and obstetric hemorrhage (43.0%). The establishment of HDU led to 20% reduction in ICU admission, which was mainly related to obstetric indications.

Conclusions

The introduction of HDU helps to reduce ICU utilization in obstetric population.

Early-term birth and its association with universal two-child policy: a national cross-sectional study in China

OBJECTIVE

To describe the epidemiology of early-term birth (ETB) at the national level in China, and explore the association and mediating factors between ETB and policy between universal two-child policy and ETB, so as to explain the potential reason for such a relationship and provide evidence for future ETB interventions in the era of the new birth control policy.

DESIGN

Cross-sectional study.

PARTICIPANTS

The cross-sectional study used data from China Labour and Delivery Survey between 2015 and 2016. A total of 75 132 survey data collected from 89 hospitals in 25 provinces were included in the analysis. We further explored the association between the universal two-child policy and ETB.

RESULTS

The weighted incidence of ETB was 30.1 per 100 all births (95% CI 30.06% to 30.14%) or 29.88 per 100 live births (95% CI 29.97% to 30.05%) between 2015 and 2016 in China. There was an association between the universal two-child policy and ETB (relative risk, RR 1.19, 95% CI 1.15 to 1.23), which was not mediated by maternal age (RR 1.17, 95% CI 1.13 to 1.22), previous uterine scars (RR 1.18, 95% CI 1.14 to 1.22), parity (RR 1.19, 95% CI 1.15 to 1.24) and other measured conditions (each p<0.05). Stratified analysis showed that the association between universal two-child policy and ETB were the strongest in multiparous young women or women without previous uterine scars (each p<0.05), and disappeared in all women of advanced maternal age (each p>0.05).

CONCLUSION

The incidence of ETB was high in China when compared with most of reported countries, and there might be a link between two-child policy and ETB. Obstetric practice such as selective induced labour and caesarean section should be revised with ETB risks in mind, when ETB is more likely to happen under the universal two-child policy. Preventing ETB should not be neglected in multiparous young women or those without previous uterine scars under the new policy.

Strangled gravidic uterus, an exceptional complication of umbilical hernia during pregnancy, a case report

Introduction

Strangulated pregnancy is a very rare presentation in which the intra umbilical strangulated form is exceptional. To our knowledge, we report the first Moroccan case and one of less than 10 cases published in the literature of a strangulated gravid uterus; in a woman admitted for treatment of umbilical pain.

Case presentation

Through this presentation, we report a sporadic case of hernial strangulation during pregnancy containing an evolving pregnancy in the umbilical harness bag. The suspicion of this diagnosis was clinical and the confirmation made by ultrasound and abdominal MRI for confirmation. The objectives of this publication are threefold: i), to report this new exceptional case ii), to highlight the place of imaging in the management of hernial pathology iii), and to recommend surgical treatment of umbilical hernias in women of childbearing age in order to avoid surgical complications and maternal and fetal morbidity and mortality.

Conclusion

Our case report shows that we should consider this very rare presentation of strangulated pregnancy. Our work also reports another new case to the poor published literature on this subject and emphasizes the importance of surgical management of parietal pathology by focusing on the parietal impact of physiological change during pregnancy.

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Atypical presentation of the strangled uterus.

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A strangled umbilical hernia containing a pregnant uterus being one of less than 10 cases reported in the literature.

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Take into consideration the possibility of complication of parietal pathology during pregnancy.

Women with maternal near-miss in the intensive care unit in Yangzhou, China: a 5-year retrospective study

BACKGROUND

Analysis of "maternal near-misses" is expected to facilitate assessment of the quality of maternity care in health facilities. Therefore, this study aimed to investigate incidence, risk factors and causes of maternal near-misses (MNM) admitted to the intensive care unit (ICU) within five years by using the World Health Organization's MNM approach.

METHODS

A five-year retrospective study was conducted in Subei People's Hospital of Yangzhou, Jiangsu Province from January 1, 2015 to December 31, 2019. Risk factors in 65 women with MNM in the intensive care unit (ICU) were explored by using chi-square tests and multivariable logistic regression analysis. Causes and interventions in MNM were investigated by descriptive analysis.

RESULTS

Average maternal near-miss incidence ratio (MNMIR) for ICU admission was 3.5 per 1000 live births. Average maternal mortality ratio (MMR) was 5 per 100,000 live births. MI for all MNM was 0.7%. Steady growth of MNMIR in ICU was witnessed in the five-year study period. Women who were referred from other hospitals (aOR 3.32; 95%CI 1.40-7.32) and had cesarean birth (aOR 4.96; 95%CI 1.66-14.86) were more likely to be admitted in ICU. Neonates born to women with MNM admitted in ICU had lower birthweight (aOR 5.41; 95%CI 2.53-11.58) and Apgar score at 5 min (aOR 6.39; 95%CI 2.20-18.55) compared with women with MNM outside ICU. ICU admission because of MNM occurred mostly postpartum (n = 63; 96.9%). Leading direct obstetric causes of MNM admitted in ICU were hypertensive diseases of pregnancy (n = 24; 36.9%), followed by postpartum hemorrhage (n = 14; 21.5%), while the leading indirect obstetric cause was heart diseases (n = 3; 4.6%).

CONCLUSIONS

Risk factors that were associated with MNM in ICU were referral and cesarean birth. Hypertensive disease of pregnancy and postpartum hemorrhage were the main obstetric causes of MNM in ICU. These findings would provide guidance to improve professional skills of primary health care providers and encourage vaginal birth in the absence of medical indications for cesarean birth.

Hepatitis B virus infection among 90 million pregnant women in 2853 Chinese counties, 2015-2020: a national observational study

BACKGROUND

China has the largest disease burden of hepatitis B virus (HBV) infection and is considered as a major contributor to the global elimination of hepatitis B by 2030. However, the national prevalence of HBV infection among Chinese pregnant women was not reported yet. We evaluated the national and regional prevalence of HBV infection among pregnant women in China between 2015-2020, aiming to provide the latest baseline data.

METHODS

We assessed the prevalence of HBV infection from data gathered through a nationwide cross-sectional study of Chinese pregnant women. Data were obtained from the National Integrated Prevention of Mother-to-Child Transmission of HIV, Syphilis and Hepatitis B Programme (iPMTCT Programme) in China, which covered all the 2856 counties from 31 provinces from 2015 to 2020. HBV infection was defined as being tested seropositive for hepatitis B surface antigen (HBsAg).

FINDINGS

A total of 90.87 million pregnant women in mainland China were testing for HBV between 2015 and 2020, with 5.60 million (6.17%, 95%CI: 6.16-6.18%) tested positive for HBsAg. From 2015 to 2020, the prevalence of HBV infection among pregnant women declined by 25.44%, from 7.30% in 2015 to 5.44% in 2020 (p for trend < 0.001), with an estimated annual percentage change (EAPC) of -5.27% (95% CI: -3.19% to -7.32%). Compared with the prevalence in 2015, reginal disparities in eastern, central, and western China were narrowed. Declines were also observed at provincial level and county level. HBV prevalence declined in most provinces (90.3%, 28/31) and counties (76.96%, 2198/2856) from 2015 to 2020. However, disparities still exist.

INTERPRETATION

HBV prevalence in pregnant women in China was intermediate endemic and declined continuously from 2015 to 2020. The decline has been widespread across regions, but disparities remain. Regions with relatively higher disease burden on HBV infection should receive most attention in achieving the 2030 elimination goals.

FUNDING

National Natural Science Foundation of China.

Maternal mortality ratio in China from 1990 to 2019: trends, causes and correlations

Background

Maternal mortality ratio is an important indicator to evaluate the health status in developing countries. Previous studies on maternal mortality ratio in China were limited to certain areas or short periods of time, and there was a lack of research on correlations with public health funding. This study aimed to assess the trends in the maternal mortality ratio, the causes of maternal death, and the correlations between maternal mortality ratio and total health financing composition in China from 1990 to 2019.

Methods

Data in this longitudinal study were collected from the China Health Statistics Yearbooks (1991–2020) and China Statistical Yearbook 2020. Linear regression analysis was used to assess the trends in the maternal mortality ratio in China. Pearson correlation analysis was used to assess the correlations between national maternal mortality ratio and total health financing composition.

Results

The yearly trends of the national, rural and urban maternal mortality ratio were − 2.290 (p < 0.01), − 3.167 (p < 0.01), and − 0.901 (p < 0.01), respectively. The gap in maternal mortality ratio between urban and rural areas has narrowed. Obstetric hemorrhage was the leading cause of maternal death. The mortalities ratios for the main causes of maternal death all decreased in China from 1990 to 2019. The hospital delivery rate in China increased, with almost all pregnant women giving birth in hospitals in 2019. Government health expenditure as a proportion of total health expenditure was negatively correlated with the maternal mortality ratio (r = − 0.667, p < 0.01), and out-of-pocket health expenditure as a proportion of total health expenditure was positively correlated with the maternal mortality ratio (r = 0.516, p < 0.01).

Conclusion

China has made remarkable progress in improving maternal survival, especially in rural areas. The maternal mortality ratio in China showed a downward trend over time. To further reduce the maternal mortality ratio, China should take effective measures to prevent obstetric hemorrhage, increase the quality of obstetric care, improve the efficiency and fairness of the government health funding, reduce income inequality, and strengthen the medical security system.

Clinical characteristics, gestational weight gain and pregnancy outcomes in women with a history of gestational diabetes mellitus

BACKGROUND

Pregnant women with a history of gestational diabetes mellitus (GDM) are at high risk of GDM. It is unclear whether this population has pregnancy characteristics different from the general population. Whether these features affect the perinatal outcome has not yet been elucidated.

METHODS

A retrospective study was conducted, including baseline characteristics, laboratory data, gestational weight gain (GWG), and pregnancy outcomes of 441 pregnant women with prior GDM. Besides, 1637 women without a history of GDM treated in the same period were randomly selected as the control group. The above indicators of the two groups were compared. Multivariable logistic regression analysis was performed to investigate how GWG was associated with perinatal outcomes for previous GDM women.

RESULTS

Among women with GDM history, triglycerides (TG) and fasting plasma glucose (FPG) in the 1st trimester were higher than those without GDM history. GWG was lower in women with prior GDM relative to the control group at various pregnancy stages. However, women with GDM history had a higher risk of developing GDM (OR 3.25, 95% CI 2.26-4.68) and pregnancy-induced hypertension (OR 1.50, 95% CI 1.05-2.45). In women with previous GDM, excessive GWG before OGTT exhibited a positive correlation with pregnancy-induced hypertension (OR 1.47, 95% CI 1.05-3.32), while inadequate GWG was not a protective factor for GDM and pregnancy-induced hypertension.

CONCLUSION

Women with prior GDM have glucose and lipid metabolism disorders in the 1st trimester. Limited reduction of GWG before oral glucose tolerance test (OGTT) was insufficient to offset the adverse effects of glucose and lipid metabolism disorders in women with previous GDM. Relevant interventions may be required at early stage or even before pregnancy.

Who are dying and why? A case series study of maternal deaths in Nepal

OBJECTIVES

To identify delays and associated factors for maternal deaths in Nepal.

DESIGN

A cross-sectional case series study of maternal deaths. An integrated verbal and social autopsy tool was used to collect quantitative and qualitative information regarding three delays. We recorded death accounts and conducted social autopsy by means of community Focus Group Discussions for each maternal death; and analysed data by framework analysis.

SETTING

Sixty-two maternal deaths in six districts in three provinces of Nepal.

RESULTS

Nearly half of the deceased women (45.2%) were primiparous and one-third had no formal education. About 40% were from Terai/Madhesi and 30.6% from lower caste. The most common place of death was private hospitals (41.9%), followed by public hospitals (29.1%). Nearly three-fourth cases were referred to higher health facilities and median time (IQR) of stay at the lower health facility was 120 (60-180) hours. Nearly half of deaths (43.5%) were attributable to more than one delay while first and third delay each contributed equally (25.8%). Lack of perceived need; perceived cost and low status; traditional beliefs and practices; physically inaccessible facilities and lack of service readiness and quality care were important factors in maternal deaths.

CONCLUSIONS

The first and third delays were the equal contributors of maternal deaths. Interventions related to birth preparedness, economic support and family planning need to be focused on poor and marginalised communities. Community management of quick transportation, early diagnosis of pregnancy risks, accommodation facilities near the referral hospitals and dedicated skilled manpower with adequate medicines, equipment and blood supplies in referral hospitals are needed for further reduction of maternal deaths in Nepal.

Burden of maternal disorders in China from 1990 to 2019: Analysis of the Global Burden of Disease Study 2019

Background

Efforts to quantify the burden of maternal disorders at the national and provincial levels are valuable for resource allocation and for development and adoption of public health policies.

Methods

Following the methods of the Global Burden of Diseases, Injuries, and Risk Factors Study 2019, the prevalence of maternal disorders and the resulting disability-adjusted life years (DALYs), years lived with disability(YLD), deaths, and years of life lost (YLL) at the national and provincial levels in China were examined for the 1990–2019 period. Estimated annual percentage changes (EAPCs) were calculated to estimate the trends of age-standardized rate (ASR) of prevalence, DALYs, death, and YLD due to maternal disorders and its main subcategories from 1990 to 2019.

Findings

In 2019, China had an estimated 0.85 million cases of maternal disorders (95% uncertainty interval: 0.65–1.08 million), with a 73% decline in absolute numbers from 1990 to 2019. The ASR of prevalence, DALYs and death for overall maternal disorders showed decreasing trends in China from 1990 to 2019 with the EAPCs being −3.25(95% confidence interval [CI] = −3.86 to −2.64), −8.07 (95% CI= −9.14 to −6.98), and −7.04 (95% CI= −7.99 to −6.07), respectively. The most pronounced decreases in trends in ASR of prevalence, DALYs and death were observed for maternal hemorrhage. Shandong, Hong Kong, Macao showed no significant trends in ASR of prevalence. Notably, the trends in ASR of prevalence due to maternal hypertensive disorders had been stable in China and most provinces. The trends in ASR of DALYs and death decreased the most in Jiangxi province.

Interpretation

The disease burden of prevalence, DALYs and death for overall maternal disorders decreased significantly in China from 1990 to 2019, however, the trends in ASR of prevalence due to maternal hypertensive disorders had been stable in China and most provinces.

Funding

The study is supported by grants from the Innovative Talent Support Plan of the Medical and Health Technology Project in Zhejiang Province (2021422878), Ningbo Science and Technology Project (202002N3152), Ningbo Health Branding Subject Fund (PPXK2018–02), Sanming Project of Medicine in Shen-zhen (SZSM201803080).

Association between the COVID-19 pandemic and the risk for adverse pregnancy outcomes: a cohort study

OBJECTIVES

The secondary impacts of the COVID-19 pandemic on adverse maternal and neonatal outcomes remain unclear. In this study, we aimed to evaluate the association between the COVID-19 pandemic and the risk for adverse pregnancy outcomes.

DESIGN

We conduced retrospective analyses on two cohorts comprising 7699 pregnant women in Beijing, China, and compared pregnancy outcomes between the pre-COVID-2019 cohort (women who delivered from 20 May 2019 to 30 November 2019) and the COVID-2019 cohort (women who delivered from 20 January 2020 to 31 July 2020). The secondary impacts of the COVID-2019 pandemic on pregnancy outcomes were assessed by using multivariate log-binomial regression models, and we used interrupted time-series (ITS) regression analysis to further control the effects of time-trends.

SETTING

One tertiary-level centre in Beijing, China PARTICIPANTS: 7699 pregnant women.

RESULTS

Compared with women in the pre-COVID-19 pandemic group, pregnant women during the COVID-2019 pandemic were more likely to be of advanced age, exhibit insufficient or excessive gestational weight gain and show a family history of chronic disease (all p<0.05). After controlling for other confounding factors, the risk of premature rupture of membranes and foetal distress was increased by 11% (95% CI, 1.04 to 1.18; p<0.01) and 14% (95% CI, 1.01 to 1.29; p<0.05), respectively, during the COVID-2019 pandemic. The association still remained in the ITS analysis after additionally controlling for time-trends (all p<0.01). We uncovered no other associations between the COVID-19 pandemic and other pregnancy outcomes (p>0.05).

CONCLUSIONS

During the COVID-19 pandemic, more women manifested either insufficient or excessive gestational weight gain; and the risk of premature rupture of membranes and foetal distress was also higher during the pandemic.