Achieving equity in maternal health in China: more to be done

China has achieved a substantial reduction in maternal mortality over the past three decades, from 88·8 deaths per 100 000 livebirths in 1990 to 21·7 deaths per 100 000 livebirths in 2014, down by 75·6%.1Ministry of Foreign AffairsPeople' Republic of ChinaUnited Nations System in China. Report on China's implementation of the Millennium Development Goals (2000–2015).http://www.fmprc.gov.cn/web/zyxw/W020150724703851768451.pdfGoogle Scholar The Article by Yanqiu Gao and colleagues2Gao Y Zhou H Singh NS et al.Progress and challenges in maternal health in western China: a Countdown to 2015 national case study.Lancet Glob Health. 2017; (published online March 21.)http://dx.doi.org/10.1016/S2214-109X(17)30100-6Summary Full Text Full Text PDF PubMed Scopus (63) Google Scholar in The Lancet Global Health is a valuable and welcome opportunity to present progress and discuss how maternal health can be improved in developing countries facing similar issues. The results of this study will help contribute to the implementation of the Sustainable Development Goals (SDGs) for health by 2030. Gao and colleagues analyse and discuss China's recent health system development and socioeconomic changes, which have been associated with a significant reduction in maternal mortality between 1994 and 2014. Their study fills in gaps in the Countdown case study series, which has focused largely on child health.3Berman P Requejo J Bhutta ZA Singh NS Owen H Lawn JE Countries' progress for women's and children's health in the Millennium Development Goal era: the Countdown to 2015 experience.BMC Public Health. 2016; 16: 791Crossref Scopus (7) Google Scholar The results show that China has made impressive progress in maternal health and has achieved Millennium Development Goal 5 to reduce maternal mortality by 75% between 1990 and 2015. However, in focusing on the relatively underdeveloped region of western China, an opportunity has been missed to examine maternal health in central China, a neglected issue of urgent concern. As shown in Gao and colleagues' study,2Gao Y Zhou H Singh NS et al.Progress and challenges in maternal health in western China: a Countdown to 2015 national case study.Lancet Glob Health. 2017; (published online March 21.)http://dx.doi.org/10.1016/S2214-109X(17)30100-6Summary Full Text Full Text PDF PubMed Scopus (63) Google Scholar the median gross domestic product per capita in 2010 for central China was only slightly higher than that of western China in 2010 (RMB ¥25 100 per person in central China vs ¥22 700 per person in western China). Some provinces in central China have a greater numbers of people living in poverty than many provinces in western China.4Department of Household SurveysNational Bureau of Statistics of ChinaPoverty monitoring report of rural China. China Statistics Press, Beijing2017Google Scholar According to the Fifth National Health Services Survey of China done in 2013, the proportion of women receiving at least five antenatal check-ups in central China was the lowest of the three regions (western, central, and eastern China), at 68·6% in urban areas and 55·2% in rural areas compared with 78·3% in urban areas and 57·1% in rural areas in western China.5Center for Health Statistics and InformationNHFPCAn analysis report of National Health Services Survey in China, 2013. Chinese Xiehe Medical University Press, Beijing2015Google Scholar Additionally, as reported by Gao and colleagues,2Gao Y Zhou H Singh NS et al.Progress and challenges in maternal health in western China: a Countdown to 2015 national case study.Lancet Glob Health. 2017; (published online March 21.)http://dx.doi.org/10.1016/S2214-109X(17)30100-6Summary Full Text Full Text PDF PubMed Scopus (63) Google Scholar the average number of licensed doctors per 1000 registered population was higher overall in western China than in central China. The results suggest that addressing maternal health challenges is equally important in central China as in western China. Another key challenge requires special attention in improving maternal health in western China. On the basis of recent estimates, China has more than 250 million so-called rural-to-urban migrants who move from the countryside to cities to seek better paid jobs.6National Health and Family Planning Commission of the People's Republic of ChinaThe report on the development of Chinese rural-to-urban migrants (2016).http://www.nhfpc.gov.cn/zhuz/xwfb/201610/a6d3a604596a4ca3acf0dad31d891c13.shtmlGoogle Scholar A substantial number of these people come from western China. Their access to affordable maternal care has become a big challenge,7Du L Qin M Zhang L Xu H Zhu L Trends in maternal mortality in resident vs. migrant women in Shanghai, China, 2000-2009: a register-based analysis.Reprod Health Matters. 2012; 20: 73-80Crossref PubMed Scopus (14) Google Scholar because health insurance policies and other maternal health entitlements are not transferrable between provinces or municipalities. However, tackling equity in access to maternal care should not only apply to the disparities between the regions, but also disparities between different social groups within a region. Hence, the development and implementation of a strategy for targeted populations, via precision poverty alleviation, to meet specific unmet needs of maternal health for different poor and vulnerable populations will be crucial for China and other developing countries. Such as strategy would be in line with China's commitment to the SDGs that "No one should be left behind".8United NationsTransforming our world: the 2030 Agenda for sustainable development, A/RES/70/1.https://sustainabledevelopment.un.org/content/documents/21252030%20Agenda%20for%20Sustainable%20Development%20web.pdfGoogle Scholar Finally, although hospital-based delivery was the main mode of skilled birth attendance in China and, as a consequence, around 75% of births occurred in hospitals at the county-level or above, maternal health care in China has not been completely medicalised. As Gao and colleagues report,2Gao Y Zhou H Singh NS et al.Progress and challenges in maternal health in western China: a Countdown to 2015 national case study.Lancet Glob Health. 2017; (published online March 21.)http://dx.doi.org/10.1016/S2214-109X(17)30100-6Summary Full Text Full Text PDF PubMed Scopus (63) Google Scholar China has extensively promoted the implementation of Essential Public Health Service programmes, through which, in rural areas, five antenatal care sessions are free of charge at the point of service use. Increasing efforts, including funding and human resources, have been put in place to support and promote health education related to maternal and child care. The central Government of China has emphasised the importance of implementing effective primary health care with a robust referral system, encouraging people to use township or community health centres nearby first, including for maternal and child health care.9The State Council of People's Republic of ChinaNational Health and Family Planning Commission of the People's Republic of ChinaGuidance on promoting the construction of classification system of diagnosis and treatment by the State Council.http://www.nhfpc.gov.cn/yzygj/s3593g/201509/c30041e1016a427f9477774c9e864eb4.shtmlGoogle Scholar China is on its way to achieving the SDGs. The key message from China's Countdown to 2015 case study suggests that further efforts to improve equity in access to maternal care ought to focus on those underserved groups who have been left behind in different parts of the country. Actions to address specific unmet needs of maternal health are imperative for these people. We declare no competing interests. Progress and challenges in maternal health in western China: a Countdown to 2015 national case studyDespite remarkable progress in maternal survival in China, substantial disparities remain, especially for the poor, less educated, and ethnic minority groups in remote areas in western China. Whether China's highly medicalised model of maternity care will be an answer for these populations is uncertain. A strategy modelled after China's immunisation programme, whereby care is provided close to the women's homes, might need to be explored, with township hospitals taking a more prominent role. Full-Text PDF Open Access