Coverage, Regional Disparity And Equity Of Key Maternal And Child Health Interventions In China

Background and objectiveDuring the past two decades, the survival status of women and children in China has been greatly improved and the Millennium Development Goals four and five established by the United Nation have been achieved. The continuum of care was conceptualized from the World Health Report in2005and later be defined by Kerber KJ et al. And lack of integration among maternal and child health system in China has hampered the improvement of the survival and health among mothers and their children. To further improve the survival and health of women and children in China, we need to internalize the continuum of care and integrate the service delivery strategy for maternal and child health system. Moreover, the general improvement of maternal and child survival may conceal the disparity across regions or subgroup populations, which is becoming another major challenge in the area of maternal and child health. Studies have identified several maternal and child survival interventions that can effectively prevent mother and their children from dying. Therefore, to close the gap of child survival across various regions or subgroup population, we need to construct a series of indicators reflect the continuum of care and analyzing of difference of coverage across region and subpopulation.Research on inequity of maternal and child health has been a hot area in recent years. In developing countries, pro-rich inequities are prevalent in maternal and child health interventions, which means inequity were found favoring urban families, mother with higher education and non-ethnical minorities. Similar findings also have reported in China. Rural residents and poor family were less covered by maternal and child health interventions.However, several literature gaps have also been identified:1) We haven’t identified any key indicators on maternal and child health interventions that represent the continuum of care.2) Different findings on inequities of antenatal and postnatal care have been reported and child health care interventions such as immunization and common childhood illnesses management have rarely been studies.3) Few inequities studies of maternal and child health at individual level have been reported. Only few studies reported the factors that contributed to the inequity found in maternal and child health interventions.Therefore, the aim of our study is to select key maternal and child health intervention indicators and to use inequity assessment approaches to measure the general coverage, regional disparity and inequity.MethodsThe data used in the analysis was from the forth National Health Service Survey (NHSS) including56456households from31provinces, autonomous regions and municipalities. The family health status survey was part of the NHSS and structured questionnaires were administered by the trained township health workers in this survey. Our analysis only included the modules of general characteristics of households, health status of family members, married women at reproductive age (15-49years of age) and children under5years of age in the family health status survey. When assessing the coverage on antenatal, intrapartum and postpartum interventions and early initiation of breastfeeding, total7414mother-child pairs were included in the analysis pool. However, when analyzing infant and young child feeding (except for early initiation of breastfeeding), immunization and childhood diarrhea and management, the sample size was9639.By reviewing international and domestic maternal and child health coverage indicators,11key coverage indicators were chosen as the core indicators. The weighted coverage of maternal and child health interventions across different regions were explored and quantified by absolute difference and ratio. The geographic mapping tool was also used to display the provincial disparities of coverage. The per capita annual consumptive expenditure was used to categorize population into five socio-economic levels, the absolute difference between the poorest20%and the richest20%, ratio of the poorest20%and the richest20%and concentration index (CI) were calculated to measure the extent of inequity. For those inequitable coverage, the pattern of inequity was also assessed by the ratio of (Q1-Q2) and (Q5-Q4) and figures. Furthermore, decomposing of CI was used to explore the factors that contributed to the inequity health interventions.Results Coverage of key maternal and child health interventionsThe coverage for at least once antenatal care and hospital delivery were94.65%and89.55%, respectively. The quality of antenatal care was measured by two indicators. One is minimum acceptable quality (including weighing, measuring blood pressure, blood routine test and urine routine test) and the coverage was62.01%. Another is at least five times of antenatal care with minimum acceptable quality and the proportion was39.08%.53.94%women received postnatal care at least once. Around72.45%of children were introduced complementary feeding between six to nine months of age while continued breastfeeding and80.38%children between12to59months of age were fully immunized (one dose of BCG and measles, three doses of DPT, HBV and polio). For children whose caregivers reported to have diarrhea two weeks prior the survey date,73.96%of them received oral rehydration therapy. However, the coverage of early initiation of breastfeeding and exclusively breastfeeding for six months were all lower than40%.Regional disparity of key maternal and child health interventionsBased on the regional and provincial analysis, the lowest coverage of key maternal and child health interventions were in western provinces such as Yunan, Guizhou, Xinjiang and Tibet. Although there were no significant differences between rural and urban areas in most of the maternal and child health key indicators, rural type IV area has the lowest coverage of antenatal care and hospital delivery. Moreover, compare to nearly universal coverage of at least once antenatal care visit (95%), at least four and five times of antenatal care visit and the minimum acceptable quality indicators were found to be low (66%,52%and62%). Only39.08%women received at least five times of antenatal care visits with minimum acceptable quality.Inequity of key maternal and child health interventionsPrevalent pro-rich inequities were found among antenatal care, delivery and postnatal care interventions, indicating those interventions were favoring the population with better socio-economic status. The extent of inequity also varied from intervention to intervention. The absolute difference and ratio between the richest20%population and the poorest20%population for at least five times of antenatal care visit and the minimum acceptable quality were57%and3.94. The coverage gap of hospital delivery between the richest20%population and the poorest20%population were smaller (difference was 25%and the ratio was1.58). On the contrary, exclusively breastfeeding for6months was pro-poor (CI=-0.93, P<0.0001) indicating children from low socio-economic families were exclusively breastfed more than their counterparts from better socio-economic families. We did not found inequity for immunization and childhood diarrhea management indicators.After analyzing the inequity pattern, interventions with high coverage (≥90%) follow the bottom pattern of inequity while interventions with low coverage (39%-70%) present a top pattern.Decomposing health inequityIn antenatal care and postnatal care, most of the consumption-related inequity was explained by the direct effect of per capita annual family consumption(percentage contribution=0.4705-1.188). Compare to crude coverage indicator of antenatal care, living in eastern/middle/western areas (percentage contribution=0.1845-0.2029) and maternal occupation (percentage contribution=0.1212-0.1264) are also seen to be the main driver of the inequity of effective coverage of antenatal care. Maternal education(percentage contribution=0.3690), per capita annual family consumption (percentage contribution=0.2401) and maternal parity (percentage contribution=0.1768) contributed to the pro-rich inequity of hospital delivery.ConclusionMaternal and child health interventions were imbalanced distributed from pregancy through delivery to childhood. Our study indicated that comparting to high coverage of antenatal care, intrapatum interventions and immunization, postnatal care and infant and young child feeding were lower. Western and rural type IV area had the lowest coverage for most of the maternal and child health interventions, suggesting further emphasized should placed on scaling-up the key maternal and child health interventions on western and remote rural areas. Although the proportion of as least once antenatal care was high, the quality of antenatal care was suboptimal with wide regional diasparity. Even the health care service utlization attained a high level, without improved quality in health care facilities and strengthened capaciliy and skill among health workers, the intervention would not benefit the population in need effectively. Pro-rich inequities were prevalent among antenatal, intrapartum and post partum cares. The inequity pattern also varied across different key maternal and child health interventions. To close the gap of inequities, tailored strategies should be implemented according to certain inequity patterns. Consumption-related inequity is mainly explained by the direct effect of per capita annual family consumption for antenatal care and postnatal care. The purchasing power of residents was seen to be the main barrier for utilization of services during pregnancy and after delivery. Living in eastern/middle/western areas and maternal occupation also explained part of the pro-rich inequity of effective coverage of antenatal care. To address to health inequity of maternal and child health interventions, targeting the disadvantage population or universal coverage can be applied. No matter what strategy is chosen, it is essential to build a maternal and child health inequity monitoring and evaluation system to continuously measure the inequity and its influential factors for maternal and child health interventions. Moreover, to identify and prospectively track of high risk population using the data from this maternal and child health inequity monitoring and evaluation system is also needed, which could facilitate evidence-based policy making on closing the gap of maternal and child health.