Background and context
Since the economic reforms of 1978, China has been acclaimed as a remarkable economy,
achieving 9% annual growth per head for more than 25 years. However, China’s health sector has
not fared well. The population health gains slowed down and health disparities increased. In the
field of health and health care, significant progress in maternal care has been achieved. However,
there still remain important disparities between the urban and rural areas and among the rural areas
in terms of economic development. The excess female infant deaths and the rapidly increasing sex
ratio at birth in the last decade aroused serious concerns among policy makers and scholars.
Decentralization of the government administration and health sector reform impacts maternal care.
Many studies using census data have been conducted to explore the determinants of a high sex
ratio at birth, but no agreement has been so far reached on the possible contributing factors. No
study using family planning system data has been conducted to explore perinatal mortality and sex
ratio at birth and only few studies have examined the impact of the decentralization of government
and health sector reforms on the provision and organization of maternal care in rural China.
Objectives
The general objective of this study was to investigate the state of perinatal health and maternal
care and their determinants in rural China under the historic context of major socioeconomic
reforms and the one child family planning policy. The specific objectives of the study included: 1)
to study pregnancy outcomes and perinatal health and their correlates in a rural Chinese county; 2)
to examine the issue of sex ratio at birth and its determinants in a rural Chinese county; 3) to
explore the patterns of provision, utilization, and content of maternal care in a rural Chinese
county; 4) to investigate the changes in the use of maternal care in China from 1991 to 2003.
Materials and Methods
This study is based on a project for evaluating the prenatal care programme in Dingyuan county in
1999-2003, Anhui province, China and a nationwide household health survey to describe the
changes in maternal care utilization. The approaches used included a retrospective cohort study,
cross sectional interview surveys, informant interviews, observations and the use of statistical data.
The data sources included the following: 1) A cohort of pregnant women followed from pregnancy
up to 7 days after birth in 20 townships in the study county, collecting information on pregnancy
outcomes using family planning records; 2) A questionnaire interview survey given to women who
gave birth between 2001 and 2003; 3) Various statistical and informant surveys data collected
from the study county; 4) Three national household health interview survey data sets (1993-2003)
were utilized, and reanalyzed to described the changes in maternity care utilization. Relative risks
(RR) and their confidence intervals (CI) were calculated for comparison between parity, approval
status, infant sex and township groups. The chi-square test was used to analyse the disparity of use
of maternal care between and within urban and rural areas and its trend across the years in China.
Results
There were 3697 pregnancies in the study cohort, resulting in 3092 live births in a total population
of 299463 in the 20 study townships during 1999-2000. The average age at pregnancy in the
cohort was 25.9 years. Of the women, 61% were childless, 38% already had one child and 0.3%
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had two children before the current pregnancy. About 90% of approved pregnancies ended in a
live birth while 73% of the unapproved ones were aborted.
The perinatal mortality rate was 69 per thousand births. If the 30 induced abortions in which the
gestational age was more than 28 weeks had been counted as perinatal deaths, the perinatal
mortality rate would have been as high as 78 per thousand. The perinatal mortality rate was
negatively associated with the wealth of the township. Approximately two thirds of the perinatal
deaths occurred in the early neonatal period. Both the still birth rate and the early neonatal death
rate increased with parity. The risk of a stillbirth in a second pregnancy was almost four times that
for a first pregnancy, while the risk of early neonatal deaths doubled. The early neonatal mortality
rate was twice as high for female as for male infants. The sex difference in the early neonatal
mortality rate was mainly attributable to mortality in second births. The male early neonatal
mortality rate was not affected by parity, while the female early neonatal mortality rate increased
dramatically with parity: it was about six times higher for second births than for first births. About
82% early neonatal deaths happened within 24 hours after birth, and during that time, girls were
almost three times more likely to die than boys. The death rate of females on the day of birth
increased much more sharply with parity than that of males.
The total sex ratio at birth of 3697 registered pregnancies was 152 males to 100 females, with 118
and 287 in first and second pregnancies, respectively. Among unapproved pregnancies, there were
almost 5 live-born boys for each girl.
Most prenatal and delivery care was to be taken care of in township hospitals. At the village level,
there were small private clinics. There was no limitation for the provision of prenatal and postnatal
care by private practitioners. They were not permitted to provide delivery care by the county
health bureau, but as some 12% of all births occurred either at home or at private clinics; some
village health workers might have been involved. The county level hospitals served as the referral
centers for the township hospitals in the county. However, there was no formal regulation or
guideline on how the referral system should work. Whether or not a woman was referred to a
higher level hospital depended on the individual midwife's professional judgment and on the
clients' compliance. The county health bureau had little power over township hospitals, because
township hospitals had in the decentralization process become directly accountable to the
township government.
In the township and county hospitals only 10-20% of the recurrent costs were funded by local
government (the township hospital was funded by the township government and the county
hospital was funded by the county government) and the hospitals collected user fees to balance
their budgets. Also the staff salaries depended on fee incomes by the hospital. The hospitals could
define the user charges themselves. Prenatal care consultations were however free in most
township hospitals. None of the midwives made postnatal home visits, because of low profit of
these services.
The three national household health survey data showed that the proportion of women receiving
their first prenatal visit within 12 weeks increased greatly from the early to middle 1990s in all
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areas except for large cities. The increase was much larger in the rural areas, reducing the
urban-rural difference from more than 4 times to about 1.4 times. The proportion of women that
received antenatal care visits meeting the Ministry of Health‘s standard (at least 5 times) in the
rural areas increased sharply from 12% in 1991-1993 to 36% in 2001-2003. In rural areas, the
proportion increase was much faster in less developed areas than in developed areas. The hospital
delivery rate increased slightly from 90% to 94% in urban areas while the proportion increased
from 27% to 69% in rural areas. The fastest change was found to be in type 4 rural areas, where
the utilization even quadrupled. The overall difference between rural and urban areas was
substantially narrowed over the period. Multiple logistic regression analysis shows that time
periods, residency in rural or urban areas, income levels, age group, education levels, delivery
history, occupation, health insurance and distance from the nearest health care facilities were
significantly associated with hospital delivery rates.
Conclusions
1. Perinatal mortality in this study was much higher than that for urban areas as well as any
reported rate from specific studies in rural areas of China. Previous studies in which calculations
of infant mortality were not based on epidemiological surveys have been shown to
underestimate the rates by more than 50%.
2. Routine statistics collected by the Chinese family planning system proved to be a reliable data
source for studying perinatal health, including still births, neonatal deaths, sex ratio at birth and
among newborns. National Household Health Survey data proved to be a useful and reliable
data source for studying population health and health services. Prior to this research there were
few studies in these areas available to international audiences.
3.Though perinatal mortality rate was negatively associated with the level of township economic
development, the excess female early neonatal mortality rate contributed much more to high
perinatal mortality rate than economic factors. This was likely a result of the role of the family
planning policy and the traditional preferences for sons, which leads to lethal neglect of female
newborns and high perinatal mortality.
4. The selective abortions of female foetuses were likely to contribute most to the high sex ratio at
birth. The underreporting of female births seemed to have played a secondary role. The higher
early neonatal mortality rate in second-born as compared to first-born children, particularly in
females, may indicate that neglect or poorer care of female newborn infants also contributes to
the high sex ratio at birth or among newborns. Existing family planning policy proved not to
effectively control the steadily increased birth sex ratio.
5. The rural-urban gap in service utilization was on average significantly narrowed in terms of
maternal healthcare in China from 1991 to 2003. This demonstrates that significant
achievements in reducing inequities can be made through a combination of socio-economic
development and targeted investments in improving health services, including infrastructure,
staff capacities, and subsidies to reduce the costs of service utilization for the poorest. However,
the huge gap which persisted among cities of different size and within different types of rural
areas indicated the need for further efforts to support the poorest areas.
6. Hospital delivery care in the study county was better accepted by women because most of
women think delivery care was very important while prenatal and postnatal care were not.
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Hospital delivery care was more systematically provided and promoted than prenatal and
postnatal care by township hospital in the study area. The reliance of hospital staff income on
user fees gave the hospitals an incentive to put more emphasis on revenue generating activities
such as delivery care instead of prenatal and postnatal care, since delivery care generated much
profits than prenatal and postnatal care .