MMR is a universally accepted indicator that describes population level health status and medical care provision. Our study reported a 28-year MMR time trend and the MMR regional comparisons. We found that the MMR decreased greatly in rural and urban areas during the study period in China, although disparity remains among regions and provinces.
From 1990 to 2018, the decline rate of MMR in urban areas was lower than that in rural areas, which may be due to the limiting effect and the improvement of medical services in rural areas . The MMR was lower in eastern China compared to western China. Natural environment, inconvenient transportation, and weaker health services may be the reasons for the high MMRs in western provinces. It was a challenge to improve population health for western underdeveloped provinces. In 2018, China's overall MMR was lower in urban areas than in rural areas, but there were still 10 provinces in which urban areas were higher than rural areas. The reason for this phenomenon was probably due to urbanization, a large rural population entered the urban areas. The economic status, health condition and education background of floating population were generally low, and the young female floating population exhibited poor awareness of health care. We should pay more attention to the floating population, improve the service ability of the public health service system to the floating population, strengthen the behavior intervention to the floating population, and improve the health awareness and disease management compliance of the floating population.
In the past three decades, the Chinese government has implemented many public health programs for maternal health care. The Basic Public Health Service Equalization project was launched by Chinese government in 2009. The goals of this project were achieving the equalization of public health services and improving the quality of life of all urban and rural residents. The Basic Public Health Service Equalization project has numerous items, one of which is improving the quality of maternal health services. Specific measures include the establishment of maternal health records, prenatal examinations and post-natal visits for rural and urban pregnant women[18, 19]. The project also requires equal quality and quantities of maternal health services to narrow the urban-rural gap. For example, maternal health providers are all trained according to national standards and required to deliver same number of maternal services for rural and urban women. The Maternal Mortality Reduction and Neonatal Tetanus Elimination program was designed by the Chinese Ministry of Health. This program focused on increasing facility births and antenatal visits. It was implemented in 378 counties in 12 western provinces in 1999, expanding coverage to a total of 2288 counties in 22 central and western provinces from 2008. The program effectively reduced maternal mortality through the enhancement of hospital delivery, and it was nationalized to ensure free hospital delivery for all women in China in 2009. The Five Strategies for Maternal and Newborn Safety program consisted of the following components: pregnancy risk screening and assessment strategy, case-by-case management strategy, referral and treatment strategy, reporting strategy for maternal deaths and accountability strategy. The Urban Employees Basic Medical Insurance, Urban Residents Basic Medical Insurance, and New Cooperative Medical Scheme were health insurances funded by central and local governments and donated by individuals. The Urban Employees Basic Medical Insurance was a compulsory health insurance started in 1999 for employees and employers in urban areas. However, the aged, kids, students, and urban non-employed rural residents were not included in the Urban Employees Basic Medical Insurance system. Therefore, in order to solve the problem, the Urban Residents Basic Medical Insurance scheme was established since 2007, and the scheme improved the health care of some groups and the inequality of health care. The New Cooperative Medical Scheme offered subsidies for rural residents on antenatal and postnatal services and encouraged hospital delivery, either as a prepayment or a retrospective reimbursement. The Chinese government proposed the 2030 Healthy China Program, which aimed to reduce the MMR to 12.0 per 100,000 birth lives by 2030. If the current decreasing trend continues to hold, this target seems achievable.
The gap between rural and urban MMRs decreased steadily from 1990 to 2010. It is noteworthy that the MMRs in rural and urban areas were almost equal in 2010, and then there was a small between rural and urban areas from 2010 to 2015. One reason for this phenomenon may be the implementation of the Basic Public Health Service Equalization project by Chinese government in 2009, which aimed to achieve the equalization of public health services and improve the quality of life of all urban and rural residents. The rural MMR in China fluctuated from 1990 to 2002. After the implementation of the New Cooperative Medical Scheme in 2003, the rural MMR showed a steadily decrease trend from 2003 to 2016.
After the implementation of the Two-Child policy in 2015, the pregnant women are more likely to be aged 35 and over both in urban and rural areas, which increased the number of high risk pregnant women. The gap of MMR between rural and urban areas increased after the launch of Two-Child policy. The MMR in rural areas in 2017 was higher than that in 2016, and the MMR in urban areas continued to decline. The medical conditions and educational level in the rural areas were relatively low. The implementation of the Two-child policy has brought challenges to rural maternal health.
The main diseases of maternal death in China were obstetric bleeding, puerperal infection, amniotic fluid embolism, pregnancy-induced hypertension, liver disease and heart disease. The maternal mortality rate caused by these major diseases all had declined from 1990 to 2018. The possible reasons for the decrease included the improvement of health care in poor areas. The decline in obstetric hemorrhage appeared to be an important contributing factor in the reduction in maternal deaths in China. Therefore, continuing to reduce the risk of death from obstetric hemorrhage was very important for reducing MMR. Measures to reduce the risk of obstetric hemorrhage included antenatal care, skilled delivery, emergency obstetric care, and post-partum care. The above measures worked best when combined with hospital delivery. Promoting hospital delivery was a very effective medical measure to reduce the risk of pregnancy-related diseases, especially in developing countries where many women traditionally gave birth at home.
To achieve the goal of the 2030 Healthy China Program and further decrease the MMR, responsible health authorities should provide community intervention therapy, raise investments in western China and rural areas, increase the percentage of total health expenditure in GDP, heighten the percentage of government in total health expenditure, and improve the quality of obstetric care. Increasing the number of well educated and trained midwives will be an important factor in improving healthcare in the coming decades.
Our study has implications for China and other low- and middle-income countries to achieve significant reductions in maternal mortality. Our study has a limitation: data on maternal deaths in some extremely remote areas may not be registered, which may make the differences between urban and rural areas and the eastern and western regions even greater. Researchers reported discrepancies between routine data and survey data related to the number of reported livebirths, child, maternal mortality, and maternal health interventions. Other research found that coverage of most health indicators in a province were lower than in the routine data, and deaths were under-reported .