Association of Maternal Mortality and Fine Management Based on Risk Screening From 2008-2017 During the Two-Child Policy Era in China: A National Longitudinal Study

Abstract

Background: Reducing maternal mortality is one of the key targets of the Sustainable Development Goals (SDGs). In response to the impact of the increase in birth rate on maternal and child safety after the release of the two-child policy in 2013, the Chinese government implemented the Five Strategies for Maternal and Newborn Safety (FRMNS) to reduce maternal mortality ratio (MMR) by fine management based on risk screening. We aimed to analyze the changes in the proportion of pregnant women at high risk screened before and after the implementation of the fine management strategy based on risk screening and its association with maternal mortality during the two-child policy era in China Methods: We conducted a nationwide longitudinal study using the data from the National Statistical Yearbook and the National Health Statistics Yearbook for all the 31 provinces during 2008-2017 to assess analyze the changes in the proportion of pregnant women at high risk screened before (2008-2013) and after (2014-2017) the implementation of the fine management strategy based on risk screening during the two-child policy era. We used generalized estimating equation (GEE) models to analyze the relationship between the proportion of pregnant women at high risk and MMR after controlling for sociodemographic factors, health resources, and other maternal healthcare factors. Findings: In the past decade, the number of livebirths in China increased by 32.3%, from 13.3 million in 2008 to 1.76 million in 2017. The median proportion of pregnant women at high risk in 31 provinces in China increased by 64.8%, from 14.87% in 2008 to 24.50% in 2017. The annualised rate of increase in the median proportion of pregnant women at high risk after the implementation of fine management (1.33%) was higher than that before the implementation (0.74%). The median MMR in China decreased by 39.6%, from 21.7 per 100,000 livebirths in 2008 to 13.1 per 100,000 livebirths in 2017. The univariate GEE models showed that MMR decreased by 7.9% per year during 2008-2017 (cRR 0.92, 95% CI 0.91-0.93), and the proportion of pregnant women at high risk was negatively correlated with MMR (cRR 0.97, 95%CI 0.94-0.99; p=0.001). In the multivariate GEE models, after adjusting for confounders, the proportion of pregnant women at high risk was still negatively correlated with MMR (aRR 0.99, 95% CI 0.98-1.00; p=0.002). In the subgroup analysis, association of MMR with GDP per capita and government health expenditure per capita existed only before the implementation of fine management; while high MMR was associated with a low proportion of pregnant women at high risk after the implementation of fine management (aRR 0.99, 95% CI 0.98-1.00; p=0.014). Interpretation: After the reform of the health care system in 2009, by implementation of the fine management strategy based on risk screening during the two-child policy era, China clarified the definition and screening scope of high-risk groups, identified and managed pregnant women at high risk, and timely transferred and treated critically ill pregnant women, and thus prompted the MMR to keep stable with a slight decline. Funding Statement: This research was supported by the National Natural Science Foundation (71874003; 81703240). Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: Missing.