Rural maternal mortality ratio in China
Authors: Hua You, Lennart Bogg, Ayesha De Costa, Hengjin Dong
Journal: The Lancet Global Health (2014)

A recent letter to The Lancet1Xi B Zhou C Zhang M Wang Y Xu L Maternal and child mortality in China.Lancet. 2014; 383: 953-954Summary Full Text Full Text PDF PubMed Scopus (20) Google Scholar drew attention to Chinese achievements with regard to Millennium Development Goals (MDGs) 4 and 5. The wide wealth and health disparities, including in maternal survival, in China, linked both to the urban–rural divide and to the east–west divide, have been noted many times.2Tang S Meng Q Chen L Bekedam H Evans T Whitehead M Tackling the challenges to health equity in China.Lancet. 2008; 372: 1493-1501Summary Full Text Full Text PDF PubMed Scopus (380) Google Scholar, 3Liang J Dai L Zhu J et al.Preventable maternal mortality: geographic/rural-urban differences and associated factors from the population-based Maternal Mortality Surveillance System in China.BMC Public Health. 2011; 11: 243Crossref PubMed Scopus (42) Google Scholar Here we draw attention to the closing gap between urban and rural maternal mortality ratio (MMR), both in terms of the drivers behind the dramatic drop in rural maternal mortality and the surprising lack of improvement in urban maternal mortality. The drop in rural maternal mortality coincides with the launch of the New Cooperative Medical Scheme (NCMS) in 2003. The scheme operates on a voluntary basis and pools funds from central and local governments, with individual contributions.4Wang YZ Development of the New Rural Cooperative Medical System in China.China World Econ. 2007; 15: 66-77Crossref Scopus (24) Google Scholar The maternity package offered under NCMS varies across counties,5Long Q Zhang Y Raven J et al.Giving birth at a health-care facility in rural China: is it affordable for the poor?.Bull World Health Organ. 2011; 89: 144-152Crossref PubMed Scopus (25) Google Scholar but it typically offers subsidies of expenses for facility-based delivery including antenatal and postnatal services, either as a prepayment or a retrospective reimbursement. In 2011, 97·5% of rural villages were enrolled in the NCMS.6Chinese Ministry of HealthChinese health service development statistics bulletin.http://www.nhfpc.gov.cn/mohwsbwstjxxzx/s7967/201204/54532.shtmlGoogle Scholar Since launch, the officially reported MMR in rural China decreased from 65·4 per 100 000 in 2003 to 26·5 per 100 000 in 2011,6Chinese Ministry of HealthChinese health service development statistics bulletin.http://www.nhfpc.gov.cn/mohwsbwstjxxzx/s7967/201204/54532.shtmlGoogle Scholar, 7Chinese Ministry of HealthYearbook of health statistics in China.http://www.nhfpc.gov.cn/htmlfiles/zwgkzt/ptjnj/year2012/index2012.htmlGoogle Scholar reaching almost the same level as the urban MMR (25·2 per 100 000 in 2011; figure). Rising hospital delivery rates were financially supported not only by NCMS, but also by other local, regional, and national programmes, especially a national Ministry of Health program called “Reducing Maternal Mortality and Eliminating Neonatal Tetanus”, launched in 2000. This programme included subsidies for hospital delivery as well as interventions to improve quality of obstetric services in hospitals. Out-of-pocket expenditure on a facility-based delivery as a percentage of annual household income decreased from 2002 to 2007. Having health insurance was associated with reduced out-of-pocket expenditure, particularly on a caesarean delivery.7Chinese Ministry of HealthYearbook of health statistics in China.http://www.nhfpc.gov.cn/htmlfiles/zwgkzt/ptjnj/year2012/index2012.htmlGoogle Scholar Elective caesarean delivery rates are reported to be higher among NCMS participants than among non-participants.8Huang K Tao F Raven J Liu L Wu X Tang S Utilization of antenatal ultrasound scan and implications for caesarean section: a cross-sectional study in rural Eastern China.BMC Health Serv Res. 2012; 12: 93Crossref PubMed Scopus (20) Google Scholar In the 8 years preceding the launch of NCMS (1994–2002) the urban MMR in China fell to a greater extent (−49·4%) than did the rural MMR (−24·9%); however, in the years subsequent to the launch of the NCMS (2003–11), rural MMR fell by 59·5% whereas the urban MMR was only reduced by 3·3% (figure). In the same period (2003–10), annual income per head in urban China rose sharply from 8400 to 19 000 CNY, whereas in rural China the rise was more modest, from 2600 to 5900 CNY (figure). Are these maternal mortality data reliable? Researchers have reported discrepancies between routine data and survey data related to the number of reported livebirths and to reported infant, child, and maternal mortality, as well as to maternal and child health interventions.9Wang L Wang LJ Cai Y Ma LM Zhou MG Analysis of under-reporting of mortality surveillance from 2006 to 2008 in China.Chi J Prev Med. 2011; 45 (in Chinese).: 1061-1064Google Scholar Du and colleagues10Du Q Naess Ö Bjertness E Yang G.H Wng LH Kumar BN Differences in reporting maternal and child health indicators: a comparison between routine and survey data in Guizhou Province.Int J of Women's Health. 2012; 4: 294-303Google Scholar found that coverage of most maternal and child health indicators in the study areas in Guizhou were lower than in the routine data, and deaths were under-reported. The researchers concluded that monitoring and evaluation for MDG goals 4 and 5 will remain objective and reliable only if estimates are based on good reporting systems. Mander11Lu L Li X The effects of the new-type rural cooperative medical system on reducing the mortality of the pregnant and lying-in women in China.Med Inform. 2010; 5 (in Chinese).: 2985-2986Google Scholar noted that a potential criticism against the reported achievements in reducing MMR relates to the authenticity of the data presented. She noted that there are issues linked to the fact that meeting government targets is connected to rewards and punishments. Chen and Xu12Chen L Xu D Trends in China's reforms: the Rashomon effect.Lancet. 2012; 379: 782-783Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar noted in The Lancet the conflicting findings from studies of the impact of NCMS. These reservations notwithstanding, it is important to call attention to the dramatic reduction in rural MMR in China and the lack of progress in the urban MMR. The levelling out of urban maternal mortality in China in the past decade calls for increased attention. A possible cause could be the influx of migrant workers and other floating population, who lack resources and access to adequate services. We declare no competing interests. This work was supported by the MATIND project, funded by the European Union (261304). The views expressed in the paper are those of the authors. We thank the masters students at Zhejiang University, School of Public Health, involved in the MATIND project team (Shengnan Duan, Yuan Wu, Chiyu Ye, Xiaofang Liu) for their support in the data collection. Maternal and child mortality in ChinaMaternal and child mortality is an important indicator of a country's health and development. In 2000, 189 governments committed to eight development goals for 2015.1 The target of Millennium Development Goal (MDG) 4 was to reduce mortality in children younger than 5 years by two-thirds between 1990 and 2015, and the target for MDG5 was to reduce the maternal mortality ratio by three-quarters during the same period. In 2008, the Countdown to 2015 initiative identified 68 priority countries (including China) for accelerated action on maternal, newborn, and child health. Full-Text PDF