Time Trends and Regional Differences in Maternal Mortality in China from 2000 to 2005/tendances Au Cours Du Temps et Variations Regionales De la Mortalite Maternelle En Chine Entre 2000 et 2005/tendencias Temporales Y Diferencias Regionales De la Mortalidad Materna En China De 2000 a 2005

Article excerpt

Une traduction en francais de ce resume figure a Ia fin de l'article. Al final del articulo se facilita una traducodn al espanol.

Introduction

Twenty years into the Safe Motherhood Initiative, countries continue to struggle to reduce the high burden of maternal death. The fifth Millennium Development Goal (MDG-5) has set a target of reducing maternal mortality by 75% between 1990 and 2015, but progress has been slow. (1,2) Effective technical interventions exist, but their application requires considerable skill. The training, deployment and retention of skilled health personnel remain huge challenges, and inequities, insufficient financial resources and lack of political will continue to limit progress. (3,4)

China represents one of the few success stories in maternal health. The maternal mortality ratio (MMR), estimated at 1500 deaths per 100 000 live births in the 1950s, (3,5) decreased to an estimated 88 deaths per 100 000 live births in 1990. (6-8) The factors explaining this decline are complex, but the successful expansion of rural health services, with an effective referral system from villages to township and county hospitals, is thought to have been a major factor. (9-11) During the past 25 years China has undergone unprecedented economic growth, and the health reforms introduced concurrently have raised concerns over rising inequalities. (12,13) There is ample evidence of inequalities between regions in access to obstetric care and maternal survival, but whether gaps increase over time is unknown. (7,13-15)

As in other countries, in China the accuracy of maternal mortality estimates is uncertain. The recent Countdown, which tracks coverage of child and maternal health indicators in 68 countries, including China, was unable to track progress towards MDG-5 because of the huge margin of uncertainty in maternal mortality estimates. (16) China's maternal mortality estimates are typically obtained from a sentinel surveillance system covering a sample of 37 urban and 79 rural sites. (17) The generalizability of these data has been called into question, and discrepancies have been noted in the classification of the causes of death. (7)

In this study we used a different source of data to examine trends and variations in the MMR in China between 2000 and 2005. The National Maternal and Child Health Routine Reporting System, established in the 1980s, covers the entire population of China. (18) We report trends in maternal mortality by province and region, and explore the extent to which the observed trends are explained by changes in the proportion of institutional births, the crude birth rate and economic growth over time.

Methods

Data

We obtained data on live births and maternal deaths in each province between 2000 and 2005 from the National Maternal and Child Health Routine Reporting System, which falls under the responsibility of the Ministry of Health. (13,18) The system differs somewhat in urban and rural areas. In urban areas, all pregnancies are registered and community doctors keep a log of all pregnancy outcomes. When the pregnancy outcome is not known, they call the woman's home to update the information. Once a month they also visit obstetric and emergency departments in their catchment area and check death certificates at the police departments to further identify maternal deaths. Community doctors send monthly reports to sub-district health managers, who forward summary reports to district health managers twice a year. In rural areas, village doctors use their extensive community networks to identify births and deaths within their catchment area. Data are forwarded monthly to township hospitals and twice a year to the county health department. Maternal deaths are defined as the death of a woman while pregnant or within 42 days of pregnancy termination, irrespective of pregnancy duration or termination method, excluding deaths from intentional and unintentional injuries. …