Effect of health system and policy on maternal and newborn health in China since 1949: a Countdown to 2015 case study

Abstract

BackgroundWith the introduction of the Millennium Development Goals 4 and 5 in 1990, analyses of progress in maternal and newborn health have focused on the last 20 years. However, China already had low maternal and neonatal mortality rates in 1990, so it is important to understand the health policy environment and health systems inputs that have underpinned progress since 1949. MethodsWe used standard tools developed by Countdown to 2015's Health Systems and Policies Technical Working Group to examine national-level changes to the health system and health policies in China since 1949 and to describe the translation of macropolicies and strategies into the implementation of maternal and newborn health programmes. We used data from the Chinese Health and Family Planning Statistical Yearbook 2013 to calculate national and subnational health workforce densities. This study used open access secondary (and anonymous) data so did not require ethical approval. ResultsThe Chinese maternal and newborn policy and programmatic environment from 1949 to present is complex. Initially, training of traditional midwives and barefoot doctors aimed to decrease maternal mortality and neonatal tetanus in rural areas. With vast economic growth from the late 1970s, well coordinated health initiatives, such as a perinatal health programme and cross-cutting strategies including the one-child policy, were implemented nationally. The 1995 Law on Maternal and Infant Health Care focused on training and service delivery for maternal and new-born health, and the 1999–2009 Safe Motherhood programme focused on increasing facility births. From 2003, the Rural Cooperative Medical System contributed to increases in hospital delivery by improving quality of service delivery, providing subsidies to pregnant women, and focusing on community health education. As a result, hospital births increased nationally from 61·7% of all live births in 1997 to 99·5% in 2013, and in western Provinces from 47·9% in 1997 to 98·5% in 2013. Enabling health system and policies substantially improved facility delivery rates in Western provinces, although large urban, rural, and provincial disparities still exist. In 2012, the density of health workforce per 1000 population in urban areas was nearly three times that of rural areas (8·54 vs 3·41), and the density of health workforce per 1000 population in Beijing Province was twice that of Sichuan Province (9·48 vs 4·82). InterpretationChina's successes in implementing health services and policies to improve maternal and newborn health could be useful to other countries. More needs to be done to decrease inequities within the country. A strength of this study is its use of standardised, novel tools to examine the effect of health system and policies on maternal and newborn health in China over a long time frame (1949 to present). A limitation of the study is that this case study looks at plausibility rather than causality, as causality cannot be inferred from these analyses in view of the data limitations and multiple concurrent changes. FundingUS Fund for UNICEF under the Countdown to 2015 for Maternal, Newborn and Child Survival grant from the Bill & Melinda Gates Foundation, Government of Canada, Foreign Affairs, Trade and Development, and Sichuan University.