Xiaohong Li

Maternal mortality in China, 1996-2005

To analyze the trend in maternal mortality ratio (MMR), characteristics and causes of maternal deaths, and factors influencing the MMR in China between 1996 and 2005.

Under-5 mortality in 2851 Chinese counties, 1996–2012: a subnational assessment of achieving MDG 4 goals in China

BACKGROUNDnIn the past two decades, the under-5 mortality rate in China has fallen substantially, but progress with regards to the Millennium Development Goal (MDG) 4 at the subnational level has not been quantified. We aimed to estimate under-5 mortality rates in mainland China for the years 1970 to 2012.nnnMETHODSnWe estimated the under-5 mortality rate for 31 provinces in mainland China between 1970 and 2013 with data from censuses, surveys, surveillance sites, and disease surveillance points. We estimated under-5 mortality rates for 2851 counties in China from 1996 to 2012 with the reported child mortality numbers from the Annual Report System on Maternal and Child Health. We used a small area mortality estimation model, spatiotemporal smoothing, and Gaussian process regression to synthesise data and generate consistent provincial and county-level estimates. We compared progress at the county level with what was expected on the basis of income and educational attainment using an econometric model. We computed Gini coefficients to study the inequality of under-5 mortality rates across counties.nnnFINDINGSnIn 2012, the lowest provincial level under-5 mortality rate in China was about five per 1000 livebirths, lower than in Canada, New Zealand, and the USA. The highest provincial level under-5 mortality rate in China was higher than that of Bangladesh. 29 provinces achieved a decrease in under-5 mortality rates twice as fast as the MDG 4 target rate; only two provinces will not achieve MDG 4 by 2015. Although some counties in China have under-5 mortality rates similar to those in the most developed nations in 2012, some have similar rates to those recorded in Burkina Faso and Cameroon. Despite wide differences, the inter-county Gini coefficient has been decreasing. Improvement in maternal education and the economic boom have contributed to the fall in child mortality; more than 60% of the counties in China had rates of decline in under-5 mortality rates significantly faster than expected. Fast reduction in under-5 mortality rates have been recorded not only in the Han population, the dominant ethnic majority in China, but also in the minority populations. All top ten minority groups in terms of population sizes have experienced annual reductions in under-5 mortality rates faster than the MDG 4 target at 4.4%.nnnINTERPRETATIONnThe reduction of under-5 mortality rates in China at the country, provincial, and county level is an extraordinary success story. Reductions of under-5 mortality rates faster than 8.8% (twice MDG 4 pace) are possible. Extremely rapid declines seem to be related to public policy in addition to socioeconomic progress. Lessons from successful counties should prove valuable for China to intensify efforts for those with unacceptably high under-5 mortality rates.nnnFUNDINGnNational Twelfth Five-Year Plan for Science and Technology Support, National Health and Family Planning Commission of The Peoples Republic of China, Program for Changjiang Scholars and Innovative Research Team in University, the National Institute on Aging, and the Bill & Melinda Gates Foundation.

Mortality rate for children under 5 years of age in China from 1996 to 2006

OBJECTIVESnTo study the change in mortality rate for children under 5 years of age in China over the past decade, and to evaluate Chinas progress in achieving Millennium Development Goal 4.nnnSTUDY DESIGNnPopulation-based descriptive study.nnnMETHODSnA population-based survey was conducted through a nationwide multi-level surveillance network. The mortality rate and the leading causes of death for children under 5 years of age were analysed.nnnRESULTSnThe mortality rate for children under 5 years of age in China dropped by 54.2% between 1996 and 2006 (from 45.0 per 1000 livebirths to 20.6). During this period, deaths due to pneumonia and diarrhoea dropped by 69.4% and 69.7%, respectively. The proportion of deaths due to pneumonia dropped from 23.4% in 1996 to 15.6% in 2006, and the proportion of deaths due to diarrhoea dropped from 5.6% in 1996 to 3.7% in 2006.nnnCONCLUSIONnThe mortality rate for children under 5 years of age in China dropped remarkably from 1996 to 2006. This reduction was mainly due to a significant decrease in deaths due to pneumonia and diarrhoea. Based on the survey results, China should be able to achieve Millennium Development Goal 4.

Preventable maternal mortality: Geographic/rural-urban differences and associated factors from the population-based maternal mortality surveillance system in China

BackgroundMost maternal deaths in developing countries can be prevented. China is among the 13 countries with the most maternal deaths; however, there has been a marked decrease in the maternal mortality ratio (MMR) over the last 3 decades. Chinas reduction in the MMR has contributed significantly to the global decline of the MMR. This study examined the geographic and rural-urban differences, time trends and related factors in preventable maternal deaths in China during 1996-2005, with the aim of providing reliable evidence for effective interventions.MethodsData were retrieved from the population-based maternal mortality surveillance system in China. Each death was reviewed by three committees to determine whether it was avoidable. The preventable maternal mortality ratio (PMMR), the ratios of PMMR (risk ratio, RR) and 95% confidence intervals (CI) were used to analyze regional disparities (coastal, inland and remote regions) and rural-urban variations. Time trends in the MMR, along with underlying causes and associated factors of death, were also analysed.ResultsOverall, 86.1% of maternal mortality was preventable. The RR of preventable maternal mortality adjusted by region was 2.79 (95% CI 2.42-3.21) and 2.38 (95% CI: 2.01-2.81) in rural areas compared to urban areas during the 1996-2000 and 2001-2005 periods, respectively. Meanwhile, the RR was the highest in remote areas, which was 4.80(95%CI: 4.10-5.61) and 4.74(95%CI: 3.86-5.83) times as much as that of coastal areas. Obstetric haemorrhage accounted for over 50% of preventable deaths during the 2001-2005 period. Insufficient information about pregnancy among women in remote areas and out-of-date knowledge and skills of health professionals and substandard obstetric services in coastal regions were the factors frequently associated with MMR.ConclusionsPreventable maternal mortality and the distribution of its associated factors in China revealed obvious regional differences. The PMMR was higher in underdeveloped regions. In future interventions in remote and inland areas, more emphasis should be placed on improving womens ability to utilize healthcare services, enhancing the service capability of health institutions, and increasing the accessibility of obstetric services. These approaches will effectively lower PMMR in those regions and narrow the gap among the different regions.

National and subnational all-cause and cause-specific child mortality in China, 1996–2015: a systematic analysis with implications for the Sustainable Development Goals

Summary Background China has achieved Millennium Development Goal 4 to reduce under-5 mortality rate by two-thirds between 1990 and 2015. In this study, we estimated the national and subnational levels and causes of child mortality in China annually from 1996 to 2015 to draw implications for achievement of the SDGs for China and other low-income and middle-income countries. Methods In this systematic analysis, we adjusted empirical data on levels and causes of child mortality collected in the China Maternal and Child Health Surveillance System to generate representative estimates at the national and subnational levels. In adjusting the data, we considered the sampling design and probability, applied smoothing techniques to produce stable trends, fitted livebirth and age-specific death estimates to natvional estimates produced by the UN for international comparison, and partitioned national estimates of infrequent causes produced by independent sources to the subnational level. Findings Between 1996 and 2015, the under-5 mortality rate in China declined from 50·8 per 1000 livebirths to 10·7 per 1000 livebirths, at an average annual rate of reduction of 8·2%. However, 181u2008600 children still died before their fifth birthday, with 93u2008400 (51·5%) deaths occurring in neonates. Great inequity exists in child mortality across regions and in urban versus rural areas. The leading causes of under-5 mortality in 2015 were congenital abnormalities (35u2008700 deaths, 95% uncertainty range [UR] 28u2008400–45u2008200), preterm birth complications (30u2008900 deaths, 24u2008200–40u2008800), and injuries (26u2008600 deaths, 21u2008000–33u2008400). Pneumonia contributed to a higher proportion of deaths in the western region of China than in the eastern and central regions, and injury was a main cause of death in rural areas. Variations in cause-of-death composition by age were also examined. The contribution of preterm birth complications to mortality decreased after the neonatal period; congenital abnormalities remained an important cause of mortality throughout infancy, whereas the contribution of injuries to mortality increased after the first year of life. Interpretation China has achieved a rapid reduction in child mortality in 1996–2015. The decline has been widespread across regions, urban and rural areas, age groups, and cause-of-death categories, but great disparities remain. The western region and rural areas and especially western rural areas should receive most attention in improving child survival through enhanced policy and programmes in the Sustainable Development Goals era. Continued investment is crucial in primary and secondary prevention of deaths due to congenital abnormalities, preterm birth complications, and injuries nationally, and of deaths due to pneumonia in western rural areas. The study also has implications for improving child survival and civil registration and vital statistics in other low-income and middle-income countries. Funding Bill & Melinda Gates Foundation.

Assessing the trend of gastroschisis prevalence in China from 1996 to 2007 using two analytical methods.

BACKGROUNDnIn recent years, the prevalence of gastroschisis has increased remarkably in some areas and remained unchanged in other areas; however, in general, there is a recent increasing trend compared to the 1970s and 1980s. In this study, we explored the time trend of gastroschisis prevalence in China during 1996 to 2007.nnnMETHODSnData were retrieved from the hospital-based national monitoring database maintained by the Chinese Birth Defects Monitoring Network (CBDMN). The monitored subjects were infants born on the 28th gestational week or later, including live births and stillbirths. The maximal time for the diagnosis of a congenital malformation was the seventh day after birth. The secular trends on the overall prevalence and the different feature-specific prevalence of gastroschisis in China were analyzed using the linear chi-square test and the Poisson regression model.nnnRESULTSnThe overall prevalence of gastroschisis in China was 2.54 per 10,000 births during 1996 to 2007. Except for the prevalence of gastroschisis that significantly increased among infants whose mothers were 20 to 24 years old (p=0.0498 for the linear chi-square test, p=0.0032 for the Poisson regression model analysis) and significantly decreased among infants whose mothers were 30 to 34 years old (p=0.0177 for the Poisson regression model analysis), no significant changes were found in the overall and remaining feature-specific prevalences.nnnCONCLUSIONnThe overall prevalence of gastroschisis in China did not change remarkably during 1996 to 2007; but the prevalence of gastroschisis significantly increased among infants whose mothers were 20 to 24 years old and decreased among infants whose mothers were 30 to 34 years old.

Sociodemographic and obstetric characteristics of stillbirths in China: a census of nearly 4 million health facility births between 2012 and 2014

BACKGROUNDnVery little is known about the burden and determinants of stillbirths in China. We used data from a national surveillance system for health facility births to compute a stillbirth rate representative of all facility births in China and to explore sociodemographic and obstetric factors associated with variation in the stillbirth rate.nnnMETHODSnWe used data from Chinas National Maternal Near Miss Surveillance System between Jan 1, 2012, and Dec 31, 2014, which covers 441 hospitals in 326 urban districts and rural counties. The surveillance aimed to enumerate all maternal deaths and near misses in health facilities, and collected data prospectively for all pregnant or post-partum women admitted to the obstetric department. We restricted the analysis to births of 28 or more completed weeks of gestation or 1000 g or heavier birthweight. We examined the strength of association between sociodemographic characteristics, gestational age, and obstetric complications and stillbirths using logistic regression, taking account of the sampling strategy and clustering of births within hospitals and in cases of more than one birth per woman.nnnFINDINGSnThere were 3u2008956u2008836 births and 37u2008855 stillbirths, giving a stillbirth rate of 8·8 per 1000 births (95% CI 8·8-8·9). The stillbirth rate was particularly high for women younger than 15 years of age (59·9 stillbirths per 1000 births), those who had not sought antenatal care (38·3 per 1000), the unmarried (32·5 per 1000), those with no education (26·9 per 1000), or those who had had four or more births (23·2 per 1000). A high proportion (29u2008319 [78·2%] of 37u2008514) of stillbirths occurred at gestational ages of younger than 37 weeks, and about two thirds (24u2008787 [66·1%] of 37u2008514) were in women without any maternal complication at the time of birth. Of babies born at normal gestations (37-41 weeks), maternal complications substantially increased the risk of stillbirth (odds ratio comparing antepartum or intrapartum complications with no complication 3·96 [95% CI 3·66-4·29]), but only a small proportion (1638 [4·4%] of 37u2008514) of stillbirths fell into this group.nnnINTERPRETATIONnOur analysis of nearly 4 million births in 441 health facilities in China suggests a stillbirth rate of 8·8 per 1000 births between 2012 and 2014. Stillbirths do not feature in the Chinese Governments 5 year plans and most information systems do not include stillbirths. The Government need to start paying attention to stillbirths and invest strategically in antenatal care, particularly for the most disadvantaged women, including the very young, unmarried, and illiterate, and those at high parity.nnnFUNDINGnNational Health and Family Planning Commission of the Peoples Republic of China, National Natural Science Foundation of China, China Medical Board, WHO, and UNICEF.

Relaxation of the one child policy and trends in caesarean section rates and birth outcomes in China between 2012 and 2016: observational study of nearly seven million health facility births

Abstract Objective To examine how the relaxation of the one child policy and policies to reduce caesarean section rates might have affected trends over time in caesarean section rates and perinatal and pregnancy related mortality in China. Design Observational study. Setting China’s National Maternal Near Miss Surveillance System (NMNMSS). Participants 6u2009838u2009582 births at 28 completed weeks or more of gestation or birth weight ≥1000 g in 438 hospitals in the NMNMSS between 2012 and 2016. Main outcome measures Obstetric risk was defined using a modified Robson classification. The main outcome measures were changes in parity and age distributions and relative frequency of each Robson group, crude and adjusted trends over time in caesarean section rates within each risk category (using Poisson regression with a robust variance estimator), and trends in perinatal and pregnancy related mortality over time. Results Caesarean section rates declined steadily between 2012 and 2016 (crude relative risk 0.91, 95% confidence interval 0.89 to 0.93), reaching an overall hospital based rate of 41.1% in 2016. The relaxation of the one child policy was associated with an increase in the proportion of multiparous births (from 34.1% in 2012 to 46.7% in 2016), and births in women with a uterine scar nearly doubled (from 9.8% to 17.7% of all births). Taking account of these changes, the decline in caesarean sections was amplified over time (adjusted relative risk 0.82, 95% confidence interval 0.81 to 0.84). Caesarean sections declined noticeably in nulliparous women (0.75, 0.73 to 0.77) but also declined in multiparous women without a uterine scar (0.65, 0.62 to 0.77). The decrease in caesarean section rates was most pronounced in hospitals with the highest rates in 2012, consistent with the government’s policy of targeting hospitals with the highest rates. Perinatal mortality declined from 10.1 to 7.2 per 1000 births over the same period (0.87, 0.83 to 0.91), and there was no change in pregnancy related mortality over time. Conclusions China is the only country that has succeeded in reverting the rising trends in caesarean sections. China’s success is remarkable given that the changes in obstetric risk associated with the relaxation of the one child policy would have led to an increase in the need for caesarean sections. China’s experience suggests that change is possible when strategies are comprehensive and deal with the system level factors that underpin overuse as well as the various incentives at work during a clinical encounter.

Hospitalized delivery and maternal deaths from obstetric hemorrhage in China from 1996 to 2006.

Objectives. To evaluate the role of hospitalized delivery in reducing maternal deaths from obstetric hemorrhage in urban and rural areas of China. Design. Longitudinal, retrospective study and review of maternal deaths based on data from the Maternal and Child Health Surveillance System (MCHSS). Setting. The surveillance areas of Maternal and Child Health in China from 1996 to 2006. Sample. A total of 6 259 336 live births and 1 418 maternal deaths from hemorrhage. Methods: Data on maternal deaths were retrieved from the MCHSS. The leading factors contributing to these deaths were reviewed by three committees. Main Outcome Measures: Maternal mortality ratio (MMR), relative risk (RR), leading factors contributing to deaths. Results. The MMR due to hemorrhage significantly decreased with increasing hospitalized delivery rates in rural areas, but it did not decrease in urban areas. The RR of maternal deaths from hemorrhage in women with non‐hospitalized delivery in comparison to hospitalized delivery were 2.52 (95% confidence interval (CI): 1.71∼3.70) in urban areas, and 5.52 (95% CI: 4.79∼6.36) in rural areas. The level of knowledge and skills of medical professionals was the leading factor contributing to 79.6% (urban) and 81.0% (rural) of the deaths during hospitalized delivery. Conclusion. The quality of obstetric care in hospitals has become one of the most important factors influencing the risk of maternal deaths from hemorrhage in China. The knowledge and skills of medical professionals need to be improved, especially in primary hospitals.