TRENDS AND POLICIES. Trends in child mortality. Trends in maternal mortality. Trends in maternal indicators

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1 Maternal and Newborn Health Country Profiles China China is on track to achieve both MDG 4 and MDG 5. The annual rate of reduction in the under-5 mortality rate was 5.8 between 1990 and Remaining challenges are reaching the previously unreached pockets of high maternal and child mortality mostly among rural dwellers and across the impoverished swaths of the western provinces and closing the policy and intervention gaps for newborns. Pockets in China encompass a large number of people; despite the significant reduction in the neonatal mortality rate, the tremendous population still leaves the country ranking second in the world for the number of preterm births each year. The availability of disaggregated data is indispensable to measure the progress made in reaching equity in coverage and health outcomes. TRENDS AND POLICIES Deaths per 1,000 live births Deaths per 100,000 live births 48 Under-5 mortality rate Trends in child mortality MDG target Infant mortality rate Trends in maternal mortality MDG target Maternal mortality ratio Neonatal mortality rate National health policies and services Availability Per capita total expenditure on health 221 (US$), Out-of-pocket expenditure (% of 35 private expenditure on health), Specific notification of maternal deaths Yes Midwifery personnel authorized to Partial administer core set of lifesaving interventions Costed national implementation plans No for maternal, newborn and child health available Number of basic emergency obstetric Not available and newborn care facilities Facilities per 1,000 births Not available Community treatment of pneumonia Partial with antibiotics Oral rehydration solution and zinc for No management of diarrhoea Sources: Confirmed by UNICEF China Country Office unless specified; 1 World Health Organization National Health Account database 2012 (retrieved from org). Trends in maternal indicators 1997 DRHS 2001 NFPRHS 2001 NSS 2006 NFPRHS 2009 NSS Per cent (%) Unmet FP Contraceptive prevalence rate Adolescent birth rate Sources for figures: Trends in child mortality: 1990 and 2010 child data from UN Interagency group for Child Mortality Estimation, Levels & Trends in Child Mortality, 2011; 2015 targets from WHO/UNICEF, Countdown to 2015 China Country Profile, 2012 (U5MR) and China s Progress Towards the MDGs, 2010 (IMR). Trends in maternal mortality: WHO/ UNICEF, Countdown to 2015 China Country Profile, Trends in maternal indicators: UNDP, Update for the MDG database, 2012 (retrieved from UNDP estimates are based on the 1997 Demographic and Reproductive Health Survey (DRHS), the 2001 and 2006 National Family Planning and Reproductive Health Survey (NFPRHS) and the 2001 and 2009 National Sample Survey on Population Changes (NSS). Notes: Contraceptive prevalence rate proportion of currently married women aged who were using some method of family planning at the time of the survey; unmet family planning need: % of women with an unmet need for family planning (spacing or limiting); adolescent birth rate: annual number of births among women aged per 1,000 women in the age group. Maternal and Newborn Health Country Profiles: China 1

2 Indicators of quality of care Antenatal care Intrapartum/delivery Postnatal care Per cent (%) ANC1+ SBA Inst. delivery C-section BF (excl.) Source: U5MR, IMR, NMR from the Chinese Statistical Yearbook 2009; maternal mortality disparities from Ministry of Health 2009 (as noted in China s Progress Towards the Millennium Development Goals, Qun Meng, Ling Xu, Yaoguang Zhang, Juncheng Qian, Min Cai, Ying Xin, Jun Gao, Ke Xu, J Ties Boerma, Sarah L Barber, Trends in access to health services and financial protection in China between 2003 and 2011: a cross-sectional study, The Lancet, 8 September 2012 Sep;380(9845):888. Notes: Comparison of data is by residence (rural versus urban versus country total) and by regions of provinces (eastern provinces versus central versus western). Availability of national policies 1 for high-impact interventions shown to improve neonatal survival throughout the continuum of care 2 Preconception Antenatal Intrapartum Postnatal - Folic acid supplmentation - Tetanus toxoid immunization - Syphilis screening - Pre-eclampsia and eclampsia prevention - Presumptive malaria treatment - Detection and treatment of asymptomatic bacteriuria - Skilled maternal and neonatal care - Emergency obstetric care - Antibiotics for PROM - Steroids for preterm labour - C-section 4 - PMTCT 4 - Resuscitation of newborn baby 3 - Breastfeeding 4 - Prevention and management of hypothermia - Kangaroo mother care - Community-based - Labour surveillance 4 - Clean delivery practices 4 pneumonia management 5 - Emergency neonatal care Legend: green: covered by policy; red: no policy or clear guideline in place. Sources: 1 All interventions discussed in the WHO China cooperation policy unless specified; 2 Darmstadt et al., 2005; 3 Chinese Journal of Child Health Care, 2010; 4 Ministry of Health; 5 Countdown to Notes: PROM: Premature rupture of membranes; emergency obstetric care: management of complications-obstructed labour, haemorrhage, hypertension, infection; C-section: caesarean section (detection and management of breech); PMTCT: prevention of mother-to-child transmission of human immunodeficiency virus (HIV); labour surveillance (including partograph) for early diagnosis of complications); kangaroo mother care (care for low birth weight infants in health facilities); emergency neonatal care: management of serious illness (infections, asphyxia, prematurity, jaundice). Reference: Darmstadt, G.L. et al., Evidence-Based, Cost-Effective Interventions: How many newborn babies can we save? The Lancet, 2005: 365 (9463). 2 Maternal and Newborn Health Country Profiles: China

3 READINESS FOR NATIONAL SCALING UP OF NEWBORN CARE Agenda setting - Focal person for newborn health in Ministry of Health - Local evidence generated for newborn survival Policy formulation - Essential drug list includes injectable antibiotics for primary level care - Midwives authorized to perform neonatal resuscitation - National targets to track newborn health established - Maternal and newborn indicators included in national health information systems - Primary-level cadres authorized to administer injectable antibiotics for newborn infections - Community-based cadres authorized to administer injectable antibiotics for newborn infections - Primary-level cadres authorized to perform neonatal resuscitation - Newborn policy integrated into other health policies or strategies Policy implementation - In-service newborn care training materials for facility-based cadres - Supervision system for maternal, newborn and child health established at primary health centre level - Integrated management of childhood illness algorithm adapted to include the first week of life - System for neonatal death audits exists - System for perinatal death audits exists - In-service newborn care training materials for community-based cadres - Pre-service newborn care education for community-based cadres (not for voluntary health cadres) - Pre-service newborn care education for facility-based cadres (not for voluntary health cadres) Agenda setting - National needs assessment for newborn care conducted - Local evidence disseminated for newborn survival - Existence of a convening mechanism for newborn health issues - Maternal and newborn indicators included in national surveys (e.g. neonatal mortality rate) Policy formulation - National newborn policy endorsed - Community-based cadres authorized to perform neonatal resuscitation - Costed implementation plan for maternal, newborn and child health - Reproductive, maternal, newborn and child expenditure per child younger than 5 years and per woman aged National behaviour change communication strategy Policy implementation - Cadre identified for home-based newborn care - Protocol or standard for district hospital care of sick newborns in place - Resource requirement for primary health care-level available for newborns - Resource requirement for scaling up home-based newborn care - In-service newborn care training materials for facility-based cadres (not for voluntary health cadres) - Resource requirement for secondary-level health care available for newborns Legend: green: benchmark met; red: benchmark not met. Source: Moran, A.C. et al Availability of benchmarks as per UNICEF China Country Office. U5MR, IMR, NMR from the Chinese Statistical Yearbook 2009; maternal mortality disparities from Ministry of Health 2009 (as noted in China s Progress Towards the Millennium Development Goals, Notes: Comparison of data is by residence (rural versus urban versus country total) and by regions of provinces (eastern provinces versus central versus western). Reference: Moran, A.C. et al., Benchmarks to Measure Readiness to Integrate and Scale Up Newborn Survival Interventions, Health Policy Planning, 2012: 27 (iii29-iii39). Maternal and Newborn Health Country Profiles: China 3

4 CONTINUING INEQUITIES: Indicators by residence, wealth quintiles and provinces Disparities by residence Maternal mortality disparities by residence and regional provices U5MR IMR Deaths per 1,000 live births Deaths per 1,000 live births Rural Urban Country total Nationwide Eastern Central Western Rural Urban Source: Mongolia MICS Notes: Comparison of data is by residence (rural versus urban versus country total), wealth quintiles (poorest versus richest versus country total) and by regions (most affected versus least affected); U5MR: Mortality for children younger than 5 years; IMR: infant mortality rate; urine sample: % of pregnant women who had their urine sample taken during an antenatal care (ANC) visit; ANC4: % of pregnant women receiving ANC 4 or more times during pregnancy (recommended # by WHO); STI screening: % of pregnant women who had a screening for sexually transmitted infections during the ANC visit; SBA: % of pregnancies delivered by skilled birth attendant; C-section: % of births delivered by caesarean section; birth reg.: % of children younger than 5 years old whose birth was registered with the State. BF excl.: % of children younger than 6 months who were exclusively breastfed; ORT/cont. feeding: % of children with diarrhoea who received oral rehydration therapy or increase intake and at the same time was continuously fed; DPT3: % of children age months who received the recommended 3 doses of DPT by 12 months. Regions: Western, Eastern, UB (Ulaanbaatar), Khangai. EQUITY FOCUS: Indicators by residence, wealth quintiles and provinces Indicator Residence Quintiles Rural Urban Poorest Wealthiest U5MR 1 (2010 country avg: 16.45%) NA NMR 2 (2010 country avg: 8.3%) IMR 2 (2010 country avg: 13.1%) Antenatal Most and least affected provinces Informed pregnancy complications at ANC, % NA NA NA NA NA (2010 country avg: 17.1%) 2 Blood pressure taken (2008 country avg: NA 90.5%) 3 Blood sample taken (2008 country avg: 67.3%) NA Urine sample taken at ANC,% (2008 country NA avg: 75%) 3 Skilled birth attendant at delivery (2010 country level: 99.6%) NA NA Highest: Beijing, Shanghai, Shandong, Hebei, etc. Lowest: Tibet Institutional delivery (2011 country level: 95.8%) Highest: Beijing, Shanghai, Shandong, Hebei, etc. Lowest: Tibet 2 4 Maternal and Newborn Health Country Profiles: China

5 Percentage delivered by C-section ( NA country level 36.3%) 4 Indicator Intrapartum Residence Quintiles Rural Urban Poorest Wealthiest Most and least affected provinces No postnatal check-up (2011 average: 5.9%) 2 NA NA NA NA Highest: Jiangsu Lowest: Tibet Postnatal care with 2 days NA NA NA NA NA Birth registration NA NA NA NA NA Exclusive breastfeeding (2008 country avg: 27.6%) NA Children younger than 5 years (76 million) 5 45 million 31 million NA NA NA % who received ORS or RHF NA NA NA NA NA % continued feeding and given ORT and/or NA NA NA NA NA increased fluids % of under-5 children with symptoms of ARI NA NA NA NA NA and/or fever whom advice or treatment was sought from a health facility or provider DPT3 (avg: 90.7%) NA Source: All information from the State of the World s Children 2012, Countdown to 2015 China Country Profile, 2012 and as per the UNICEF China Country Office, unless specified; 1 MOH, Report on Women and Children s Health Development in China, 2011; 2 Health Statistical Yearbook, 2011; 3 China National Health Service Survey 2008; 4 Qun Meng et al., Trends in Access to Health Services and Financial Protection in China Between 2003 and 2011: A cross-sectional study, The Lancet, 2012; 379: ; 5 NBS, Tabulation on the 2010 Population Census of the People s Republic of China, 2012, China Statistics Press. China Ministry of Health Document (C-section). Available at: China Ministry of Health Document (PMTCT). Available at: China Ministry of Health Document (Labour surveillance). Available at: China Ministry of Health Document (Clean delivery). Available at: Chinese Journal of Child Health Care. May Vol. 18 No. 6 (439) China Ministry of Health Document (Breastfeeding). Available at: Maternal and Newborn Health Country Profiles: China 5

6 Evidence leads to greater investment in child survival Spotlight on UNICEF work To understand why China s newborn mortality rate is more than double in rural areas compared with urban populations, the National Centre for Women and Children and UNICEF surveyed mothers of newborns who had died in poor rural areas (two counties in Xinjiang Province and two counties in Yunnan Province). They first learned that that more than half of neonatal deaths occurred at home (either the birth took place at home or the mother had returned from the facility) or en route to or from a health facility. More than half 54 per cent of the mothers explained that the transportation and treatment costs constrained their seeking care. To then understand why children, including newborns, are not covered by insurance and why children die at home without a parent seeking the health services, the Ministry of Health and UNICEF conducted a case-control study incorporating verbal and social autopsies, looking for biological and social determinants of infant death. The study also included a review of national and provincial policies on insurance schemes. From that investigation they discovered that the rural health insurance scheme in many counties did not cover newborn illness 33 per cent of the infants alive and 81 per cent among those who had died in the surveyed households were not covered. Because revenue collection is once a year, children born after that time period must wait until the next collection period to join the New Cooperative Medical Scheme. Background Autopsies of situations in which neonatal mortality is high indicate that transport and treatment costs keep many mothers from seeking care for newborn complications. Even where innovative insurance schemes successfully strengthen the social protection floor, many infants are missing out. China has made substantial progress on reducing its child and maternal mortality through a basic health social security system that started in 2008 (targeting urban employees) and combined insurance and social assistance that targeted all farmers and rural residents through a New Cooperative Medical Scheme started in 2003 and a special subsidy covering hospital deliveries started in The medical insurance scheme is co-financed and subsidized by the central and local government, farmers cooperatives and families. The facility birth subsidy in rural areas contributed significantly to reducing the financial barriers to seeking care. Yet, more than half of children younger than 5 years who die succumb to a complication within the first 28 days of life of every 18 deaths, 11 are in the newborn period, largely due to birth asphyxia or a pre-term birth. After UNICEF specialists calculated the total funding needed for the central Government to cover all newborns in rural areas in western China, the Ministry of Health initiated a strategy for ensuring every newborn s financial access to health services to remedy the financial barrier bottleneck in health care access for infant children. The Ministry then requested that all provincial authorities automatically enroll newborns into the Cooperative Medical Scheme if the mother was enrolled. In some provinces, all newborns are automatically enrolled whether the mother is or not. The Ministry of Health is working with the Ministry of Finance to explore the prospect of automatically enrolling all newborns nationwide without any individual financial contribution required. UNICEF/China/2012/Thomas Billhardt The current basic package includes out-patient care (curative care), essential drugs and hospitalization (inpatient care). The insurance scheme reimburses only per cent of costs, with the 40 per cent remaining as co-payment or out-of-pocket payment. However, the Government plans to eventually offer a reimbursement rate of 80 per cent. Maternity care nurses helping to ensure clean delivery conditions 6 Maternal and Newborn Health Country Profiles: China