The number of maternal deaths in Bao’an district had been pushed down to zero in 2018, and still remained as of today, which had in advance met the Sustainable Development Goals (SDGs) target level of pushing MMR down to 70 per 100,000 live births before 2030 . The mean annual reduction rate of MMR (12.03%) was much faster than the target pace in Millennium Development Goal (MDG) 5 of 5.5% per year.7 Substantial variation in MMR and profile of maternal death across different subgroups were also found in this paper. Migrant or out-of-hospital delivery people had a higher MMR, but a greater proportion of being determined as preventable death. This report provides the first estimate of the levels and trends of MMR at the district level over a 20-year period, and its breakthrough in reducing maternal deaths might provide a case study for other regions.
The rapid reduction of MMR in Bao’an district might be an excellent reflection of the implementation effects of the quaternity maternal health service network with fully regional coverage, namely: community health service centers as net bottom, primary hospitals with midwifery qualification as foundation, local maternal and child health hospital as core, and higher level of medical institutions as technical support, among which Bao’an Women’s and Children’s Hospital was in charge of integrated managements for nearly 50,000 parturients within the jurisdiction every year. Health service providers at all levels had devoted substantial efforts to providing systematic and high-quality prenatal, delivery and postpartum care, and the rate of maternal systematic management in this way rapidly increased in the latest decade, as follows:
First prenatal examination was provided and maternal health file was established by all hospitals, those who were graded for high risk (e.g., with severe complications) were referral to subspecialty clinics for specially-assigned management and follow-up. A green channel service was developed for obstetric emergencies at all hospitals and two obstetric emergency centers were set up to ensure critically ill pregnant women were rescued in time. On the other side, consulting services through pregnancy schools or midwife clinics were actively promoted to improve maternal health education. With respect to delivery management, first-aid training was carried out extensively to strengthen support and supervision of obstetric rescue capacity, particularly in private hospitals. For instance, skill competition for the rescue of amniotic fluid embolism was held annually as this was the first cause of death during delivery in Bao’an district. In addition, Bao’an district had taken the lead in implementing labor analgesia since 2008 to lower the rate of cesarean section, which could also partly contribute to the reduction of maternal mortality as cesarean delivery was associated with increased risk of death . After delivery, two free door-to-door postnatal visit services (within two weeks postpartum) were timely arranged by health staff from community health service centers, to provide postpartum rehabilitation guidance as well as depression screening for safeguarding maternal physical and psychological health.
Beyond that, since the reform and opening-up, a large unregistered migrant population had rushed into Shenzhen to take better-paid work away from their rural villages. Generally, they were characterized by low educational level, poorly paid, and unwilling to seek health care knowledge and service . Besides, with the still prevailing traditional concept of “more children, more blessing”, many families would rather take risks to give excess births regardless of the national one-child family planning policy. Therefore, many families chose to delivery at home or in the illegal underground clinic in the past years for saving money and avoiding substantial fined. A previous study  had pointed out that low percentages of in-hospital delivery rate might contribute to the high maternal mortality rate, which our data was in line with.
To improve this situation, Bao’an district had taken the lead in implementing delivery assistance mechanism for impoverished pregnancy women in 2000, and two supporting measures from the local Reducing Maternal Mortality and Eliminating Neonatal Tetanus Programme (also known as the“Reducing & Eliminating” Programme) had been carried out since 2005: 1) developed a poverty alleviation channel for impoverished pregnant women to ensure certain fee waiver not only in prenatal examination and in-hospital delivery but also in emergency rescue. And 2) carried out special actions to crack down on illegal medical practices and birth delivering. Great improvements had been achieved since the in-hospital delivery rate had increased from 98.96% in 2002 to 99.82% in 2018, and the proportion of maternal deaths among out-of-hospital delivery had been significantly decreased in the most recent decade.
In the same period, the maternal health workforce in Bao’an district had been developed rapidly, the numbers of well educated and highly trained obstetrician and midwife per 1000 lying-in women were 7.76 and 5.69 in 2018, with an annualized rate of increase of 6.74% and 3.99% since 2007, respectively (Supplemental Table). In short, the quaternity maternal health services network along with the “Reducing & Eliminating” Programme, and the constant improvements in access to maternal health-care resources and services, might all have contributed to the fast decline in MMR in Bao’an district.
More importantly, aiming to identify the most appropriate interventions to reduce maternal death, Bao’an district had established the maternal mortality review committees in 2000. Every death case was reviewed by a multidisciplinary expert team through three links (individual, family and community, health care institutions, other social departments such as transportation, education) and four aspects (knowledge and skill, attitude, resource and management). Nearly ninety percent of maternal deaths were determined to be preventable during the past two decades, and the preventability differed greatly between subgroups, indicating that multiple factors involving maternal death should be concerned, such as improving migrant women’s self-health care consciousness and reducing social inequities.
Yet it should not be ignored that, the high maternal mortality rate among women aged ≥ 35 years still reminded us the new risk of maternal and child safety in the coming decade and much remains to be done. Since the national family planning policy had been adjusted from January 1st, 2016 , the newly “universal two-child” policy and the transition of fertility concept had brought severe challenges to reduce maternal deaths, as the proportion of pregnant women aged ≥ 35 years, who were at higher risk of maternal mortality , had been continuously increased from 12.13% in 2016 to 17.06% in the first half-year of 2019 in Bao'an district (data from SZMCHS).
Several limitations of this analysis needed to be mentioned. First, due to the large time span and the imperfect data collection mechanism in the early years, information on the maternal deaths were not collected in a consistent form, resulting in some missing indicators which were of great analytical value. Second, descriptions about demographic characteristics of maternal deaths were limited, largely due to the natural deficiency of SZMCHS. As described previously , data in SZMCHS were primarily used for administrative reports rather than researches. Last but not least, it was more meaningful to classify the out-of-hospital delivery location instead of using the rough word-“delivering outside the hospital”. Nevertheless, with limited sample sizes, it was unable to conduct further grouping considering the stability of statistical efficiency. The aforementioned flaws all pointed out the importance and necessity of enhanced data collection and updated system for recording detailed information on every death case.
In summary, Bao’an district had experienced a fast decline in MMR for a two-decade period, its experience in lowering MMR could provide a guideline for other regions to focus on those who needed particular attention and take targeted interventions to reduce maternal deaths.