Ethnicity and MCH outcomes: widening gaps across time and space
Authors: Lei Wang, Scott Rozelle
Journal: The Lancet Global Health (2017)

The systematic review that is published in The Lancet Global Health by the collaborative team1Huang Y Shallcross D Pi L Tian F Pan J Ronsmans C Ethnicity and maternal and child health outcomes and service coverage in western China: a systematic review and meta-analysis.Lancet Glob Health. 2017; (published online Nov 16.)http://dx.doi.org/10.1016/S2214-109X(17)30445-XPubMed Google Scholar from the London School of Hygiene & Tropical Medicine (LSHTM) and Sichuan University is critical to our understanding of human capital gaps between ethnic minorities and Han individuals (China's ethnic majority). Regardless of the maternal and child health (MCH) outcome, women and their children from ethnic minority groups in China perform far worse than their Han counterparts. If anything, the authors underplay the inequalities in at least three ways. First, although the paper reports large gaps between ethnic minorities and Han Chinese across a number of MCH outcomes, these gaps are probably underestimated. The reason is because the comparisons are based almost solely on the MCH outcomes of ethnic minority and Han populations in less developed regions. It is well known that some of the largest inequalities in China today are between urban and rural areas2Sicular T Ximing Y Gustafsson B et al.The urban–rural income gap and inequality in China.Rev Income and Wealth. 2007; 53: 93-126Crossref Scopus (373) Google Scholar, 3Qian X Smyth R Measuring regional inequality of education in China: widening coast–inland gap or widening rural–urban gap?.J Int Dev. 2008; 20: 132-144Crossref Scopus (107) Google Scholar, 4Yang D T Urban–Biased Policies and Rising Income Inequality in China.Am Econ Rev. 1999; 89: 306-310Crossref Scopus (249) Google Scholar and between different geographical regions.5Zhang Q Zou H Regional Inequality in Contemporary China.Ann Econ Financ. 2012; 13: 113-137Google Scholar In other words, because the authors only compare the differences in MCH outcomes between Han and ethnic minorities living in poor rural areas of western China, they are neglecting to consider the gaps that exist between these areas and the more prosperous urban areas, and particularly urban areas in eastern China. The extent to which the gap is underestimated is illustrated by our own research examining the prevalence of anaemia among children in urban China (7%),6Li L Luo R Sylvia S et al.The prevalence of anemia in central and eastern China: evidence from the China health and nutrition survey.Southeast Asian J Trop Med Public Health. 2015; 46: 306PubMed Google Scholar a sample of Han children mostly from rural areas of eastern or central China (13%),6Li L Luo R Sylvia S et al.The prevalence of anemia in central and eastern China: evidence from the China health and nutrition survey.Southeast Asian J Trop Med Public Health. 2015; 46: 306PubMed Google Scholar and children living in rural areas of western China that are mainly inhabited by ethnic minority communities (51%).7Luo R Wang X Liu C et al.Alarmingly high anemia prevalence in western China.Southeast Asian J Trop Med Public Health. 2011; 2: 1204-1213Google Scholar The authors reported odds ratios of around 2·0 in their paper. In the case of childhood anaemia, the prevalence among ethnic minorities is 7·5 (4·0) times that of Han subpopulations in urban (rural) areas. Second, while the systematic review showed that Han-non Han ethnic minority gaps in MCH outcomes were large in the past (eg, the 1990s), there is no evidence that the gap has been narrowing. In the study by Huang and colleagues1Huang Y Shallcross D Pi L Tian F Pan J Ronsmans C Ethnicity and maternal and child health outcomes and service coverage in western China: a systematic review and meta-analysis.Lancet Glob Health. 2017; (published online Nov 16.)http://dx.doi.org/10.1016/S2214-109X(17)30445-XPubMed Google Scholar because most of the papers that fit their criteria for this review used data from 2000 to 2009, it was impossible for the authors to conduct trend analysis with any degree of confidence. In examining the results, two things stand out. First, there has been little work done on MCH health outcomes among poor ethnic minority communities since 2010. This seems to be evidence of the low level of attention that this subpopulation in China receives. Second, when the authors did examine changes in MCH outcomes over time, they showed that gaps were widening between ethnic minorities and Han Chinese in measures of maternal mortality, whether pregnant women had at least one antenatal visit/five or more antenatal visits, whether pregnant women had their first natal visit in the first trimester, and whether women gave birth in a government- approved health facility. The only measure the authors assessed where the outcome gap narrowed was hepatitis B vaccine. Finally, we believe that the main metric the authors used to evaluate MCH outcomes—access to MCH services—does not capture the seriousness of the problem in rural China, particularly among poor ethnic minority communities This is because access to MCH services does not reflect the quality of rural health care, which is one of the greatest challenges facing China's health officials today. Although there have been major improvements in access to health services across all of China, work published by the World Bank reports that there have not been corresponding improvements in health outcomes in rural communities.8Luo R Yue A Zhou H et al.The effect of a micronutrient powder home fortification program on anemia and cognitive outcomes among young children in rural China: a cluster randomized trial.BMC Public Health. 2017; 17: 738Crossref PubMed Scopus (35) Google Scholar Recent work by a group headed by Sean Sylvia at University of North Carolina and Yaojiang Shi in Shaanxi Normal University suggest that this is probably because the quality of rural health providers (that is, village clinicians and township doctors) is incredibly low.9Gauri V Are incentives everything? Payment mechanisms for health care providers in developing countries. World Bank, Washington DC2001Crossref Google Scholar, 10Sylvia S Shi Y Xue H et al.Survey using incognito standardized patients shows poor quality care in China's rural clinics.Health Policy Plan. 2014; 30: 322-333Crossref PubMed Scopus (90) Google Scholar Their research, for example, found that, in certain cases, when an individual visits a village clinician, the probability of having a proper diagnosis is less than 25% and it is more likely that individuals will receive harmful treatment than beneficial treatment. Therefore, this paper by Huang and colleagues1Huang Y Shallcross D Pi L Tian F Pan J Ronsmans C Ethnicity and maternal and child health outcomes and service coverage in western China: a systematic review and meta-analysis.Lancet Glob Health. 2017; (published online Nov 16.)http://dx.doi.org/10.1016/S2214-109X(17)30445-XPubMed Google Scholar should be seen more as an indication of the severity of inequalities in MCH outcomes than as an end product. China, as a nation, clearly has the resources to begin to address this problem. We hope that the message of this study—and in some small way this linked comment—will not only raise awareness of the gaps that exist in MCH outcomes, but will also motivate improvements in health for not only individuals living in poor ethnic minority communities, but also across all of China. We declare no competing interests. Ethnicity and maternal and child health outcomes and service coverage in western China: a systematic review and meta-analysisChina has a wealth of primary data that could further our understanding of why ethnic minority populations are lagging behind. As MCH outcomes continue to improve nationally, ethnic minorities will take a greater share of the overall burden of adverse outcomes, requiring strategic investments to address the specific challenges faced by people living in remote areas. Full-Text PDF Open Access