Study On Evaluation For Safe Motherhood Policy Of Guangxi

Ⅰ.BackgroundAlthouth the global Safe Motherhood Initiative was launched in 1987,the maternal mortality ratio(MMR) in some countries does not decrease significantly till now.An estimated 529,000 women die each year worldwide during pregnancy,childbirth or immediate postpartum,in which almost 99 percent maternal deaths take place in developing countries.The development and sustainability of maternal health care policy depends on whether the policy process is scientific,which is comparatively deficient in many developing countries.In order to reduce MMR,Guangxi Zhuang Automous Region launched the safe motherhood policy with the focus of improving rate of institutional delivery since 1998.The scientific evidence is very important to determine the priority of intervention at different policy stages and the future pathway of safe motherhood policy.The policy stakeholders wish to understand the development process and implementation effectiveness of policy and these informations need to be obtained and analysed through scientific theoretics and methodology.Currently,there lack of systematic,comprehensive and in-depth evaluation of policy process and implementation effectiveness for Guangxi safe motherhood policy,lack of satisfactory answers for the questions concerned by policy stakeholders,lack of convincing information to provide evidence-based suggestion for further policy development.This study is intended to narrow those gaps to some extent,and is served for facilitating the policy development and maternal health care improvement in Guagnxi.Ⅱ.Study goalThis study is to conduct a formative evaluation for development process of Guangxi safe motherhood policy and focus on discussing the impacts of key policy determinants on policy process,to evaluate the implematation effectiveness of policy from the aspect of improvement of maternal health service utilization and the aspect of characteristic changes of maternal death,together with evaluating the macroscopic development direction of policy,and to provide evidence-based policy suggestions in order to promote policy makers and health managers find new demands and facilitate the further development of policy.Ⅲ.Study contents and methodologies1.Using non-random,convenience sampling to select 8 mothers,2 mother-in-laws,2 village woman directors,2 village maternal health workers and 5 former traditional birth attendants in 3 counties to conduct narrative interviews,to sample a total of 13 key policy informants including polictician,policy maker,health manager,doctor, civil society organization,international NGO officer to conduct semi-structured in-depth interviews,combined with using of literature analysis method.The policy formative evaluation model was used to conduct the formative evaluation for Guangxi safe motherhood policy from aspects of policy context,policy process,policy contents and policy actors with the focus on the impacts of key determinants of health system, human resources,service deliver),and civil society on policy process.2.With Guangxi databank of the 3^rd National Heatlh Service Survey as baseline data, the post-intervention data of policy intervention derived from the investigation of 594 women in 6 counties who had live delivery history in the last 3 years using multi-stage stratified randomized sampling.Using Anderson health service utilization behavioral model as analytical framework to evaluate the improvement of institutional delivery service utilization of Guagnxi rural pregnant women and analyse its determinants.3.Using the surveillance data of Guangxi pregnant women death between 1998 to 2006 to evaluate the characteristic changes of maternal death,analyse the causes of death of pregnant women and the determinants of the death place.4.Using Guangxi MCH routine annual reporting data to evaluate the comprehensive implementation effectiveness of Guangxi safe motherhood policy with technique for order preference by similarity to ideal solution(TOPSIS method).To set up a mathematic predict model of MMR of Guangxi using autoregressive integrated moving average model(ARIMA model) and conduct a extrapolated prediction in the near future.To propose evidence-based policy suggestions to facilitate further effective implementation of policy.Ⅳ.Main study results1.Since Guangxi safe motherhood policy was launched in 1998,all levels of governments attach high importance to it and all society participate in it positively. Through some effective strategies including transforming the function of traditional birth attendants,setting up and perfecting towmship essential obstetric centers and county emergency obstetric centers,subsidy of institutional delivery by New Rural Cooperative Medical Scheme(NCMS) combined with the Project of Lowering MMR and Eliminating Newborn Tetanus(PLMENT),free picking up pregnant woment to hospital and free waiting for delivery in hospital,safe motherhood stretcher action in mountainous areas and positive supporting by civil society orgamzations,four key policy determinants,namely health system management,human resources,service delivery and civil society,interact positively to facilitated successfully the policy development.The rate of institutional delivery of Guangxi increased from 45.67%in 1998 to 93.75%in 2007,the maternal mortality ratio and infant mortality ratio decreased respectively from 86/100,000 and 23‰to 24.06/100,000 and 12.64‰, which all achieve the targets of Guangxi Outline for Women's Development in 2010 in advance of 4 years.2.The rate of home delivery was 58.72%and the rate of institutional delivery was only 39.80%at baseline survey.The rate of institutional delivery increased to 92.09% at post-intervention survey and the rate of delivery in township health center was 66.67%.The rate of home delivery decreased gradually and the rate of delivery in township health center and county level hospital showed the increased tendency gradually(P＜0.001),especially for the rate of delivery in township health center.The main causes of home delivery at baseline survey was economic difficulty.(46.03%), backward consciousness(21.34%),precipitate labor(17.57%) and traffic difficulty (9.62%) by order,and the main causes of home delivery at post-intervention survey was economic difficulty(37.78%),precipitate labor(35.75%),traffic difficulty (17.78%) and backward consciousness(6.67%) by order.The policy intervention showed better result in terms of promoting institutional delivery for those pregnant women who were the minority,the elder,the peasant,the non-high risky,with low education background,the poor,living in distant from health center,with few times of prenatal checkup,late for first prenatal checkup and multiparas.3.Multivariate logistic regression analysis showed the determinants of institutional delivery service utilization at baseline survey were delivery history,nationality, education background of pregnant women,the type of family drinking water,time needed to get to the nearest hospital by the most convenient traffic,whether or not be advocated to institutional delivery and the frequency of prenatal checkup.The OR value were 25.579 for those with over 5 times of prenatal checkup,7.865 for those being advocated to institutional delivery,4.479 for those with education of senior middle school,2.735 for those drinking tap water,1.856 for those getting to hospital in less than 10 min,1.71 for primiparas and 1.508 for Han nationality respectively. After policy intervention,the determinants of institutional delivery utilization were nationality,knowing the subsidy of institutional delivey,knowing the phone of obstetric emergency aid,accepting the education of pregnant women school,being able to get the subsidy from NCMS or PLMENT,the education background of husband,getting the pamphlet of maternal health care,the frequency of prenatal checkup and whether or not considering it should utilize maternal health service positively.The OR value were 482.758 for those being able to get subsidy from NCMS,137.912 for those being able to get subsidy from PLMENT,18.673 for those with over 5 times of prenatal checkup,17.88 for those knowing the phone of obstetric emergency aid,12.672 for those whose husband with education of senior middle school,10.554 for those knowing the subsidy of institutional delivery,7.769 for Han nationality,7.431 for those thinking it should utilize maternal health service positively, 4.555 for those getting the pamphlet of maternal health care and 4.049 for those accepting the education of pregnant women school respectively.The policy intervention mainly eliminated the impacts of delivery history,economic accessibility and traffic accessibility on institutional delivery utilization,however,nationality, education background,quality of prenatal health care service,consciousness of maternal health care and social mobilization are still the important determinants of institutional delivery service utilization.4.The policy intervention increased the coverage rate of prenatal checkup(P＜0.05), the average frequency of prenatal checkup(P＜0.05),the average frequency of postpartum visiting(P＜0.05) and shifted the average time of first prenatal checkup to an earlier time(P＜0.05).The rate of accepting education of pregnant women school was 48.31%at the post-intervention survey and the education of antepartum screening and screening against neonatal disease should be strengthened.Quality of antenatal checkup was high.The average items of prenatal checkup was 8.27 and 72.14%of women accepted the wholly 9 items of antenatal checkup.The average items of postpartum visiting was 5.65 and only 20.85%of women accepted over 8 items of postpartum visiting.It should improve the quality of postpartum visiting further.The satisfactory degree of hospital service was high on the whole after policy intervention and the proportion of women who thought the hospital service were satisfactory increased from 50%at baseline survey to 78.98%at post-intervention survey.The consciousness of maternal health care was high on the whole after policy intervention. The most primary source of acquiring maternal health care knowledge was to come from doctor with the rate of 75.87%,the second source was through propaganda slogan with the rate of 22.30%and the third source was through pregnant women school with the rate of 22.12%.5.Through the deduction of subsidy from NCMS and PLMENT,the median of actual expense of normal delivery in township health center and in county level hospital at post-intervention survey were 60 and 150 Yuan respectively lower than at baseline survey.Policy intervention improved the economic accessibility of aquiring institutional delivery.6.Within the dead pregnant women,the proportion of those who lived in mountainous areas,who were illiterates,who were the poorest,who never accepted prenatal checkup showed the declined tendency gradually(P＜0.05).The proportion of women who died at home showed the declined tendency gradually and women who died at county and above level hospitals showed the raising tendency gradually(P＜0.0501).7.The main cause of maternal death was obstetric hemorrhage(44.25%),amnionic fluid embolism(9.95%),pregnancy combined with heart disease(9.51%) and gestational hypertension(9.29%).The proportional mortality rate of hemorrhage showed the declined tendency gradually and the proportional mortality rate of the amnionic fluid embolism showed the raising tendency gradually(P＜0.05).The first two causes of postpartum hemorrhage was placental retention(31.75%) and uterine inertia(27.50%),besides,the proportional mortality rate of placental retention showed the declined tendency gradually(P＜0.001).8.The proportion of avoidable maternal death and avoidable maternal death by creating condition showed the declined tendency gradually,the proportion of unavoidable maternal death showed the raising tendency gradually(P＜0.001).The primary problems within avoidable maternal death and avoidable maternal death by creating condition were personal,family and medical facilities's knowledge and skill problems,within which the proportion of personal and family knowledge problems was 68.03%and the proportion of medical facilities's knowledge and skill problems was 21.58%.9.Multinomial logistic regression analysis showed that the nationality,education background,delivery history,situation of family planning,dwelling space,family per capita yearly income and frequency of prenatal checkup were determinants of maternal death place.Compared with dying at home,those with education of senior middle school(OR=11.78),those living in plain areas(OR=2.726),primiparas (OR=2.036),those with 4000-8000 family per capita yearly income(OR=1.917) and those with Han nationality(OR=1.904) had the higher probability of dying at county level hospitals.And compare with dying at home,those with education of senior middle school(OR=3.594),those with over 5 times of prenatal checkup(OR=2.879), those with Han nationality(OR=2.383),those within the family planning(OR=1.647) and primiparas(OR=1.396) had the higher possibility of dying at towhship health centers.The research results suggested the pregnant women with minority,those outside of the family planning,those with low education background,those with poor family economy,those dwelling in mountainous areas,those with low frequency of prenatal checkup and multiparas had the low accessibility of obtaining institutional delivery or obtaining emergency aid when subjected with fatal obstetric risk,hence, they had more possibility of dying at home.Those pregnant women should be the key population of policy intervention.10.The comprehensive implementation effectiveness of Guangxi safe motherhood policy showed the increasing tendency as a whole using evaluation of TOPSIS method.The MMR of Guangxi in 2008 is predicted as 17.695/100,000 using ARIMA time series model. Ⅴ.Policy recommendation1.To maintain favorable external environments beyond the heatlh sectors and clarify the dominant position and public responsibility of all levels of government in the development of Guangxi safe motherhood policy.2.To further strengthen the cooperation with civil society and establish the efficient coordinated and integrated mechanism between Guangxi safe motherhood policy and other social policies.3.To increase the funding input of maternal health care enterprise continuously and formulate the institutional funding guaranteeing mechanism and input increasing mechanism of maternal health care.4.To establish the universal crowd-coveraged,function-perfected and rational work-divided maternal health care service system.(1).To strengthen the construction of rural essential obstetric service centers,increase the service capacity and quality,establish and perfect the efficient mutual referral system between various levels of maternal health service networks.(2).To strengthen the construction of obstetric human resources,formulate the long-term development strategy of maternal health human resources of Guangxi.(3).To establish the coordinated mechanism between MCH system and family planning system and bring the pregnant women outside of the family planning into systematic management of maternal health care wholly.5.To establish the maternity waiting home to further increase the geographic accessibility of remote rural pregnant women to institutional delivery service.6.To adopt the health promotion strategy appropriately with the highly emphasis of minority and low education background pregnant women,integrate the knowledge of maternal health care into compulsory education to increase the sustainability of institutional delivery.