Abstract
BackgroundContinuum of care for maternal health services (CMHS) is a proven approach to improve health and safety for mothers and newborns. This study aims to explore the influence of China’s 2009 healthcare reform on improving the CMHS utilisation.MethodsThis population-based cross-sectional quantitative study included 2332 women drawn from the fourth and fifth National Health Service Surveys of Shaanxi Province, conducted in 2008 and 2013 respectively, before and after China’s 2009 healthcare reform. A generalised linear mixed model (GLMM) was applied to analyse the influence of this healthcare reform on utilisation of CMHS. Concentration curves, concentration indexes and its decomposition method were used to analyse the equity of changes in utilisation.ResultsThis study showed post-reform CMHS utilisation was higher in both rural and urban women than the CMHS utilisation pre-reform (according to China’s policy defining CMHS). The rate of CMHS utilisation increased from 24.66 to 41.55% for urban women and from 18.31 to 50.49% for rural women (urban: χ2 = 20.64, P < 0.001; rural: χ2 = 131.38, P < 0.001). This finding is consistent when the WHO’s definition of CMHS is applied for rural women after reform (12.13% vs 19.26%; χ2 = 10.99, P = 0.001); for urban women, CMHS utilisation increased from 15.70 to 20.56% (χ2 = 2.57, P = 0.109). The GLMM showed that the rate of CMHS utilisation for urban women post-reform was five times higher than pre-reform rates (OR = 5.02, 95%CL: 1.90, 13.31); it was close to 15 times higher for rural women (OR = 14.70, 95%CL: 5.43, 39.76). The concentration index for urban women decreased from 0.130 pre-reform (95%CI: − 0.026, 0.411) to − 0.041 post-reform (95%CI: − 0.096, 0.007); it decreased from 0.104 (95%CI: − 0.012, 0.222) to 0.019 (95%CI: − 0.014, 0.060) for rural women. The horizontal inequity index for both groups of women also decreased (0.136 to − 0.047 urban and 0.111 to 0.019 for rural).ConclusionsChina’s 2009 healthcare reform has positively influenced utilisation rates and equity of CMHS’s utilisation among both urban and rural women in Shaanxi Province. Addressing economic and educational attainment gaps between the rich and the poor may be effective ways to improve the persistent health inequities for rural women.
Highlights
The maternal mortality ratio (MMR) has rapidly reduced globally during the past decades, declining from 385 to 216 maternal deaths per 100,000 livebirths between 1990 and 2015 [1]
The rate of care for maternal health services (CMHS) utilisation increased from 24.66 to 41.55% for urban women and from 18.31 to 50.49% for rural women. This finding is consistent when the World Health Organisation (WHO)’s definition of CMHS is applied for rural women after reform (12.13% vs 19.26%; χ2 = 10.99, P = 0.001); for urban women, CMHS utilisation increased from 15.70 to 20.56% (χ2 = 2.57, P = 0.109)
The generalised linear mixed model (GLMM) showed that the rate of CMHS utilisation for urban women postreform was five times higher than pre-reform rates (OR = 5.02, 95%Confidence Limits (CL): 1.90, 13.31); it was close to 15 times higher for rural women (OR = 14.70, 95%CL: 5.43, 39.76)
Summary
The maternal mortality ratio (MMR) has rapidly reduced globally during the past decades, declining from 385 to 216 maternal deaths per 100,000 livebirths between 1990 and 2015 [1]. Despite global progress in reducing maternal mortality, MMR in low- and middle-income countries (LMICs) is still seven times higher than in highincome countries [2]. Prenatal care penetration is high, with more than 80% of pregnant women attending ≥4 antenatal visits and delivering in hospital, yet only 25% of women receive ≥3 postnatal visits within 42 days after delivery [3, 4]. One possible means of further reducing the MMR in China would be improving adherence to postnatal visits through continuity of care (COC). COC for maternal health services (CMHS) utilisation is defined by pregnant women attending antenatal visits, delivery in health facilities and receiving postnatal visits from health professionals in their homes continuously from pregnancy to 42 days after delivery [7]. This study aims to explore the influence of China’s 2009 healthcare reform on improving the CMHS utilisation
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