Analysis of inequality in maternal and child health outcomes and mortality from 2000 to 2013 in China

Trend and Equity in Maternal and Child Health Resource Allocation in China Since the New Health System Reform: A Nationwide Study from 2008 to 2020

Purpose

China has made considerable efforts to promote the development of maternal and child health (MCH) care since the new health system reform in 2009. This study aims to evaluate the trend and equity of MCH resources allocation in China from 2008 to 2020 and provide a reference for rational distribution of MCH resources.

Methods

Data were collected from the China Health Statistics Yearbook and China Statistics Yearbook. The number of MCH hospitals, licensed (assistant) physicians, registered nurses and beds were selected for the measurement of the equity of MCH resources allocation. The Health Resource Agglomeration Degree and Theil index were used in evaluating MCH resource allocation equity and to compare differences among regions.

Results

From 2008 to 2020, the average annual growth rates for MCH hospitals, beds, licensed (assistant) physicians, and registered nurses were 0.72%, 6.95%, 5.04%, and 9.57%, respectively. However, regional disparities in the equity of MCH resource allocation have been identified. Although the western region has shown growth in MCH resource allocation by geography, the agglomeration degree of the four indicators remains less than 1, significantly lower than the average value of greater than 2 in the eastern region. Additionally, the equity of human resource allocation in the western region is lower than the equity in the allocation of institutions. In the densely populated eastern region, the equity of MCH resource allocation by population is decreasing, with the agglomeration degree of all four indicators below 1 in 2020. The disparity in healthcare resource allocation within regions is the main cause of inequitable MCH resource allocation in China.

Conclusion

The allocation of MCH resources in China has improved since 2009, however, geographic equity needs further improvement, particularly in densely populated regions. Population and geographic balances should be considered in the development and implementation of MCH resource allocation policies, and improving intraregional equity should be the focus.

Spatiotemporal trends and geographic disparities in spatial accessibility to maternal and child health services in Nanning, China: impact of two-child policies

BACKGROUND

China's family planning policies have experienced stages of one-child policy, partial two-child policy, and universal two-child policy. However, the impact of these policy shifts on the spatial accessibility to maternal and child health (MCH) services for women and children remains uncertain. This study aimed to evaluate the spatiotemporal trends and geographic disparities in spatial accessibility to MCH services in the context of two-child polices.

METHODS

This study was conducted in Nanning prefecture, China, from 2013 to 2019. Data on the transportation networks, MCH institutes, the annual number of newborns, and the annual number of pregnant women in Nanning prefecture were collected. Gaussian two-step floating catchment area (Ga2SFCA) method was employed to measure the spatial accessibility to MCH services at county, township, and village levels. Temporal trends in spatial accessibility were analyzed using Joinpoint regression analysis. Geographic disparities in spatial accessibility were identified using geographic information system (GIS) mapping techniques.

RESULTS

Overall, the spatial accessibility to MCH services showed an upward trend from 2013 to 2019 at county, town, and village levels, with the average annual percent change (AAPC) being 5.04, 4.73, and 5.39, respectively. Specifically, the spatial accessibility experienced a slight downward trend during the period of partial two-child policy for both parents only children (i.e., 2013-2014), a slight upward trend during the period of partial two-child policy for either parent only child (i.e., 2014-2016) and the early stages of universal two-child policy (i.e., 2016-2018), and a large upward trend in the later stages of universal two-child policy (i.e., 2018-2019). Spatial accessibility to MCH services gradually decreased from central urban areas to surrounding rural areas. Regions with low spatial accessibility were predominantly located in remote rural areas.

CONCLUSION

With the gradual opening of the two-child policies, the spatial accessibility to MCH services for women and children has generally improved. However, significant geographic disparities have persisted throughout the stages of the two-child policies. Comprehensive measures should be considered to improve equity in MCH services for women and children.

The global burden, risk and inequality of maternal obstructed labor and uterine rupture from 1990 to 2019

BACKGROUND

Obstructed labor (OL) and uterine rupture (UR) are common obstetric complications. This study explored the burden, risk factors, decomposition, and health inequalities associated with OL and UR to improve global maternal health.

METHODS

This was a cross-sectional analysis study including data on OL and UR from the Global Burden of Diseases, and Risk Factors Study (GBD) 2019. The main outcome measures included the number and age-standardized rate (ASR) of incidence, disability-adjusted life years (DALYs), prevalence, and deaths.

RESULTS

The global burden of OL and UR has declined, with a decrease in incidence (number in 2019: 9,410,500.87, 95%UI 11,730,030.94 to 7,564,568.91; ASR in 2019: 119.64 per 100,000, 95%UI 149.15 to 96.21; estimated annual percentage change [EAPC] from 1990 to 2019: -1.34, 95% CI -1.41 to -1.27) and prevalence over time. However, DALYs (number in 2019: 999,540.67, 95%UI 1,209,749.35 to 817,352.49; ASR in 2019: 12.92, 95%UI 15.63 to 10.56; EAPC from 1990 to 2019: -0.91, 95% CI -1.26 to -0.57) and deaths remain significant. ASR of DALYs increased for the 10-14 year-old age group (2.01, 95% CI 1.53 to 2.5), the 15-19 year-old age group (0.07, 95% CI -0.47 to 0.61), Andean Latin America (3.47, 95% CI 3.05 to 3.89), and Caribbean (4.16, 95% CI 6 to 4.76). Iron deficiency was identified as a risk factor for OL and UR, and its impact varied across different socio-demographic indices (SDIs). Decomposition analysis showed that population growth primarily contributed to the burden, especially in low SDI regions. Health inequalities were evident, the slope and intercept for DALYs were - 47.95 (95% CI -52.87 to -43.02) and - 29.29 (95% CI -32.95 to -25.63) in 1990, 39.37 (95%CI 36.29 to 42.45) and 24.87 (95%CI 22.56 to 27.18) in 2019. Concentration indices of ASR-DALYs were - 0.2908 in 1990 and - 0.2922 in 2019.

CONCLUSION

This study highlights the significant burden of OL and UR and emphasizes the need for continuous efforts to reduce maternal mortality and morbidity. Understanding risk factors and addressing health inequalities are crucial for the development of effective interventions and policies to improve maternal health outcomes globally.

Association between maternal health service utilization and under-five mortality rate in China and its provinces, 1990-2017

BACKGROUND

The United Nations (UN) Sustainable Development Goal - 3.2 aims to eliminate all preventable under-five mortality rate (U5MR). In China, government have made efforts to provide maternal health services and reduce U5MR. Hence, we aimed to explore maternal health service utilization in relation to U5MR in China and its provinces in 1990-2017.

METHODS

We obtained data from Global Burden of Disease 2017, China Health Statistics Yearbook, China Statistical Yearbook, and Human Development Report China Special Edition. The trend of U5MR in each province of China from 1990 to 2017 was analyzed using Joinpoint Regression model. We measured the inequities in maternal health services using HEAT Plus, a health inequity measurement tool developed by the UN. The generalized estimating equation model was used to explore the association between maternal health service utilization (including prenatal screening, hospital delivery and postpartum visits) and U5MR.

RESULTS

First, in China, the U5MR per 1000 live births decreased from 50 in 1990 to 12 in 2017 and the average annual percentage change (AAPC) was - 5.2 (p < 0.05). Secondly, China had a high maternal health service utilization in 2017, with 96.5% for prenatal visits, 99.9% for hospital delivery, and 94% for postnatal visits. Inequity in maternal health services between provinces is declining, with hospital delivery rate showing the greatest decrease (SII, 14.01 to 1.87, 2010 to 2017). Third, an increase in the rate of hospital delivery rate can significantly reduce U5MR (OR 0.991, 95%CI 0.987 to 0.995). Postpartum visits rate with a one-year lag can reduce U5MR (OR 0.993, 95%CI 0.987 to 0.999). However, prenatal screening rate did not have a significant effect on U5MR.

CONCLUSION

The decline in U5MR in China was associated with hospital delivery and postpartum visits. The design and implementation of maternal health services may provide references to other low-income and middle-income countries.

Global achievement of maternal health-related sustainable development goals targets among women exposed to intimate partner violence

Health-related Sustainable Development Goal (SDG 3) aims to ensure healthy lives. This study investigates the influence of Intimate Partner Violence (IPV) on achieving maternal health related SDG3 targets among exposed women globally.

METHODOLOGY

This study used secondary data analysis of Domestic Violence Modules from the latest Demographic and Health Surveys (DHS) of 40 countries. IPV was defined by women ever exposed to emotional, physical, severe, or sexual violence from the spouse. Achieving maternal health related SDG3 targets among women was measured by: Proportion of births attended by skilled health personnel; Antenatal care (women received antenatal care eight or more times from any provider); and the need for family planning satisfied with modern methods. The influence of IPV was estimated through adjusted OR after controlling for socioeconomic factors using logistic regression.

RESULTS

Exposure to IPV was among one-third of the women (37%) mainly physical (29%) and emotional (24%). Adjusted OR with 95%CI for the influence of IPV on women's utilization of skilled birth attendants was 0.81 (0.79-0.83)); having eight or more antenatal care visits 0.61 (0.59-0.63); and the needs for family planning with modern methods satisfied was 0.85 (0.83-0.87). Achievement of maternal health services was among 57% of the women. Women exposed to IPV were less to achieve maternal health services (50% VS 61%) with adjusted OR 0.71; 95%CI: 0.70-0.73 and it was not confounded by the positive effect of socioeconomic factors.

CONCLUSION & RECOMMENDATION

Exposure to IPV had a statistically significant negative influence on all the maternal health related SDG3 services among women. Programs working in facilitating the achievement of the SDGs related maternal health targets should include prevention of women's exposure to IPV and support for those who are exposed to it.

The Pediatrician Workforce in the United States and China

From 2019 to 2022, the For Our Children project gathered a team of Chinese and American pediatricians to explore the readiness of the pediatric workforce in each country to address pressing child health concerns. The teams compared existing data on child health outcomes, the pediatric workforce, and education and combined qualitative and quantitative comparisons centered on themes of effective health care delivery outlined in the World Health Organization Workforce 2030 Report. This article describes key findings about pediatric workload, career satisfaction, and systems to assure competency. We discuss pediatrician accessibility, including geographic distribution, practice locations, trends in pediatric hospitalizations, and payment mechanisms. Pediatric roles differed in the context of each country's child health systems and varied teams. We identified strengths we could learn from one another, such as the US Medical Home Model with continuity of care and robust numbers of skilled clinicians working alongside pediatricians, as well as China's Maternal Child Health system with broad community accessibility and health workers who provide preventive care.In both countries, notable inequities in child health outcomes, evolving epidemiology, and increasing complexity of care require new approaches to the pediatric workforce and education. Although child health systems in the United States and China have significant differences, in both countries, a way forward is to develop a more inclusive and broad view of the child health team to provide truly integrated care that reaches every child. Training competencies must evolve with changing epidemiology as well as changing health system structures and pediatrician roles.

Effects of climate-related risks and extreme events on health outcomes and health utilization of primary care in rural and remote areas: a scoping review

BACKGROUND

Rural populations are at risk of climate-related impacts due to ecological and geographical determinants, potentially leading to greater morbidity and health utilization. They are often highly dependent on primary care services. However, no rural- or primary care specific synthesis of these issues has ever been conducted. This review aimed to identify, characterize, and summarize existing research on the effects of climate-related events on utilization and health outcomes of primary care in rural and remote areas and identify related adaptation strategies used in primary care to climate-related events.

METHODS

A scoping review following PRISMA-ScR guidelines was conducted, examining peer-reviewed English-language articles published up to 31 October 2022. Eligible papers were empirical studies conducted in primary care settings that involved climate-related events as exposures, and health outcomes or utilization as study outcomes. Two reviewers independently screened and extracted relevant information from selected papers. Data were analysed using content analysis and presented using a narrative approach.

RESULTS

We screened 693 non-duplicate papers, of those, 60 papers were analysed. Climate-related events were categorized by type, with outcomes described in terms of primary, secondary, and tertiary effects. Disruption of primary care often resulted from shortages in health resources. Primary care may be ill-prepared for climate-related events but has an important role in supporting the development of community.

CONCLUSIONS

Findings suggest various effects of climate-related events on primary care utilization and health outcomes in rural and remote areas. There is a need to prepare rural and remote primary care service before and after climate-related events.

Measuring the Inequalities in the Distribution of Public Healthcare Resources by the HRDI (Health Resources Density Index): Data Analysis from 2010 to 2019

Background: In China, a developing country, the imbalance of development exists in different fields, and the inequalities in the distribution of healthcare services have garnered increasing attention. This study aimed to assess the healthcare services allocation and compare the latest distribution ratios of the essential healthcare indicators with the national requirement values announced by the government to research the level of healthcare development in China. Methods: Data were extracted from the Chinese Statistical Yearbook (2010–2019). The Healthcare Resource Density Index (HRDI) was used to evaluate equity in the demographic and geographical dimensions. The requirement values related to the ratio of doctors, nurses, and institution beds per thousand people were drawn from government documents. The data of healthcare serviceability indicators were compared with those requirements to check the situation of each province’s medical development. Results: From 2010 to 2018, there was a sustainable upward trend in government investment, however, a noticeable drop in the investment in northeast areas was seen. Although the HRDI of the institutions, beds, doctors, and nurses experienced some small fluctuations over the years, the developing areas in the middle-west areas had almost approached the level of developed east areas. There were only four provinces that met the requirements of the government in all three indicators (the ratio of institution beds, doctors, and nurses per thousand people). Conclusion: The equality of the distribution of healthcare services in China was unfair between the eastern and middle-western areas. The government launched the developing requirements and paid additional attention to narrowing the imbalance among different economic level regions to meet the needs of the local people. Although many provinces did not meet the requirements for medical resources in 2019, the distribution of healthcare services was approached relatively equitably countrywide.

The Effect of Nursing Intervention Model Using Mobile Nursing System on Pregnancy Outcome of Pregnant Women

Due to the recent advancement in technology specifically mobile phones, these devices can be used in the hospital to monitor or speed up various activities, which are related to doctors and nurses. In literature, various mechanisms have been presented to resolve this issue, but none of these approaches have considered effectiveness of this technology in the development of a proper mobile nursing system, which is specifically designed for pregnant women. Therefore, in this paper, we have explored the effect of the intervention model based on the mobile nursing system on the pregnancy outcome of pregnant women. In this study, an Android-based mobile nursing monitoring system was adopted to monitor and transmit the human physiological data through physiological parameter monitoring equipment and continuously monitor the physiological parameter data of pregnant women. If the physiological health data of the pregnant woman was abnormal, it had to implement timely nursing intervention. In this study, 266 pregnant women in the electronic records (E-records) were selected as the research objects and divided into two groups according to the intervention method. Pregnant women in group A received routine physical examination during pregnancy, while those in group B received nursing intervention based on mobile nursing system. The results showed that the incidence of each indicator of pregnancy outcome in group B was significantly lower than that in group A, and the difference was statistically significant (P < 0.05). The nursing intervention model based on the mobile nursing system can effectively improve the pregnancy outcome. The mobile nursing system can help nursing staff find the abnormalities of pregnant women during pregnancy and give effective nursing measures in time, which helped improve the pregnancy outcomes, reduce the probability of adverse pregnancy outcomes, ensure the safety of puerperae and newborns, and lessen the delivery risk factors.

Hukou-based rural-urban disparities in maternal health service utilization and delivery modes in two Chinese cities in Guangdong Province

BACKGROUND

Most existing research on rural-urban health inequalities focuses on disparities in service access and health outcomes based on region. This paper examines rural-urban disparities in maternal healthcare utilization and delivery modes based on household registration (hukou) status to understand the role of state institutions in producing healthcare disparities in China.

METHODS

Utilizing administrative data from the Public Maternal Health Insurance scheme, we analyzed 54,733 live births in City A (2015-2019) and 25,849 live births in City B (2018-2019) in Guangdong Province in China. We constructed regression models using hukou status (rural versus urban) as the explanatory variable.

RESULTS

While there is no statistically significant difference in rural and urban mothers' probability of obtaining the minimum recommended number of prenatal care checkups in City A (OR = 0.990 [0.950, 1.032]), mothers with rural hukou status have a lower probability of obtaining the minimum recommended number of visits in City B than their counterparts with urban hukou (OR = 0.781 [0.740, 0.825]). The probability of delivering in tertiary hospital is lower among mothers with rural hukou than among those with urban hukou in both cities (City A: OR = 0.734 [0.701, 0.769]; City B: OR = 0.336 [0.319, 0.354]). Mothers with rural hukou are more likely to have a Cesarean section than those with urban hukou in both cities (City A: OR = 1.065 [1.027, 1.104]; City B: OR = 1.127 [1.069, 1.189]). Compared with mothers with urban hukou, mothers with rural hukou incurred 4 % (95 % CI [-0.046, -0.033]) and 9.4 % (95 % CI [-0.120, -0.068]) less in total medical costs for those who delivered via Cesarean section and 7.8 % (95 % CI [-0.085, -0.071]) and 19.9 % (95 % CI [-0.221, -0.177]) less for those who delivered via natural delivery in City A and City B, respectively.

CONCLUSIONS

Rural hukou status is associated with younger age, no difference or lower probability of having a minimum number of prenatal checkups, higher likelihood of delivering in nontertiary hospitals, increased Cesarean delivery rates, and lower medical cost for delivery in these two Chinese cities. Evaluating how hukou status influences maternal healthcare in Chinese cities is important for devising targeted public policies to promote more equitable maternal health services.

Reproductive outcomes after floxuridine-based regimens for gestational trophoblastic neoplasia: A retrospective cohort study in a national referral center in China

OBJECTIVE

To analyze the reproductive outcomes of gestational trophoblastic neoplasia (GTN) patients who were cured only by floxuridine-based regimens.

METHODS

This was a retrospective analysis of 464 patients who were treated with only floxuridine-based regimens at Peking Union Medical College Hospital between January 2002 and December 2013 and retained their reproductive ability. Their reproductive outcomes were analyzed. The factors affecting pregnancy intention were identified by logistic regression.

RESULTS

Of the 464 patients (average age, 28.0 ± 5.7 years; median follow-up = 85 months), the livebirth rate was 72.2%, while the rates of spontaneous abortion, induced abortion and ectopic pregnancy were 9.2% (n = 41), 8.7% (n = 39) and 1.8% (n = 8), respectively. The GTN recurrence rate was 2.1%. The time from chemotherapy completion to first conception in the induced abortion group was significantly shorter than those in spontaneous abortion, full-term/premature, and ectopic pregnancy groups (P ≤ 0.001, <0.001, =0.015, respectively). The logistic analysis showed that the age at onset of GTN (OR = 0.899, 95% CI 0.851-0.951, P < 0.001), parity at onset of GTN (parity = 1, OR = 0.123, 95% CI 0.068-0.225, P < 0.001; parity = 2-3, OR = 0.058, 95% CI 0.014-0.232, P < 0.001) and interval from the index pregnancy to chemotherapy were independent factors affecting pregnancy intention. Among the 36 pregnancies occurring within 12 months postchemotherapy, only one choriocarcinoma occurred, and 20 culminated in induced abortions (55.6%).

CONCLUSIONS

After floxuridine-based chemotherapy, the pregnancy rate of GTN patients after fertility-preserving treatment is comparable to that of the normal population. Pregnancy losses within one year after chemotherapy completion are mainly caused by induced abortion.

Anatomy of provincial level inequality in maternal mortality in China during 2004-2016: a new decomposition analysis

BACKGROUND

The maternal mortality ratio (MMR) is an important indicator of maternal health and socioeconomic development. Although China has experienced a large decline in MMR, substantial disparities across regions are still apparent. This study aims to explore causes of socioeconomic related inequality in MMR at the province-level in China from 2004 to 2016.

METHODS

We collected data from various issues of the China Health Statistics Yearbook, China Statistics Yearbook, and China Population and Employment Statistics Yearbook to construct a longitudinal sample of all provinces in China. We first examined determinants of the MMR using province fixed-effect models, accounted for socioeconomic condition, health resource allocation, and access to health care. We then used the concentration index (CI) to measure MMR inequality and employed the direct decomposition method to estimate the marginal impact of the determinants on the inequality index. Importance of the determinants were compared based on logworth values.

RESULTS

During our study period, economically more deprived provinces experienced higher MMR than better-off ones. There was no evidence of improved socioeconomic related inequality in MMR. Illiteracy proportion was positively associated with the MMR (p < 0.01). In contrast, prenatal check-up rate (p = 0.05), hospital delivery rate (p < 0.01) and rate of delivery attended by professionals (p = 0.02) were negatively associated with the MMR. We also find that higher maternal health profile creation rate (p < 0.01) was associated with a pro-poor change of MMR inequality.

CONCLUSION

Access to healthcare was the most important factor in explaining the persistent MMR inequality in China, followed by socioeconomic condition. We do not find evidence that health resource allocation was a contributing factor.

Determinants of life expectancy and clustering of provinces to improve life expectancy: an ecological study in Indonesia

BACKGROUND

Life expectancy acts as a population measure of the performance of healthcare systems. Regional disparities on life expectancy in Indonesia has been persisted and become a public health policy challenge. A systematic clustering of provinces can be a valuable alternative for organizing cooperation that aimed to increase life expectancy and reduce disparities. This study aimed to identify determinants of life expectancy and designate clusters of Indonesian provinces with similar characteristics. This approach can be useful in generating alternative cooperation strategies to improve life expectancy.

METHODS

We carefully selected variables that have been shown to impact life expectancy and gathered 2015 data from Indonesia's Ministry of Health. All 34 Indonesian provinces were included as analysis units. We performed structural equation modeling (SEM) to select domains that needed to work on from theoretical models. Based on SEM results, we performed cluster analysis to arrange cooperation groups.

RESULTS

Life expectancy showed correlations with mean years of schooling, expenditure per capita, health workforce, healthcare facilities, and environment. Expenditure per capita also was the strongest of all constructs. Based on SEM results, we performed cluster analysis to arrange cooperation groups of total 34 provinces and generated five clusters of provinces.

CONCLUSIONS

Enhancing the economy is the most effective approach for improving life expectancy and other constructs. These clusters can build cooperation that is new, within, and across clusters. These results may be useful in formulating cooperation strategies aimed at increasing life expectancy.

Efficiency of health resource utilisation in primary-level maternal and child health hospitals in Shanxi Province, China: a bootstrapping data envelopment analysis and truncated regression approach

BACKGROUND

District- and county-level maternal and child health hospitals (MCHHs) are positioned to provide primary maternal and child healthcare in rural and urban areas of China. Their efficiencies and productivity largely affect the equity and accessibility of maternal and child health care. This study aimed to assess the efficiency of district- and county-level MCHHs in China and identify their associated factors.

METHODS

Thirty-three district- and 84 county-level MCHHs were selected from Shanxi Province in 2017. At the first stage, bootstrapping data envelopment analysis (DEA) models were established to calculate the technical efficiency (TE), pure technical efficiency (PTE) and scale efficiency (SE) of district- and county-level hospitals. At the second stage, the estimated efficiency scores were regressed against external and internal hospital environmental factors by using bootstrap truncated regression to identify their determinants.

RESULTS

The average TE, PTE and SE scores for district-level MCHHs were 0.7433, 0.8633 and 0.9335, respectively. All hospitals were found to be weakly efficient, although more than 50% of the hospitals performed with efficient SE (SE scores≥100%). As for county-level MCHHs, their average TE, PTE and SE scores were 0.5483, 0.6081 and 0.9329, respectively. The hospitals with TE and PTE scores less than 0.7 accounted for more than 60%, and no hospital was observed to operate effectively. Truncated regressions suggested that the proportion of health professionals, including doctors, nurses, pharmacists, inspection technician and image technician (district level: β = 0.57, 95% CI = 0.30-0.85; county level: β = 0.33, 95% CI = 0.15-0.52), and the number of health workers who received job training (district level: β = 0.67, 95% CI = 0.26-1.08; county level: β = 0.34, 95% CI = 0.14-0.54) had a positive association with efficiency scores. The amount of financial subsidy (β = 0.07, 95% CI = 0.05-0.09) was found to be directly proportional to the productive efficiency of the county-level MCHHs.

CONCLUSION

The operational inefficiency of district- and county-level MCHHs in Shanxi Province is severe and needs to be substantially improved, especially in terms of TE and PTE. Hiring additional medical personnel and ensuring the stability of the workforce should be prioritised. The Chinese government must provide sufficient financial subsidy to compensate for service costs.

Maternal Health and Green Spaces in China: A Longitudinal Analysis of MMR Based on Spatial Panel Model

The positive impact of green spaces on public health has attracted increasing attention, and maternal health has also been shown to be related to green spaces. However, there are different kinds of green space indicators that represent different mechanisms for mitigating maternal health, and few studies have investigated the different relevance amongst them with longitudinal data. This study explores the correlation between various green space indicators and maternal health using spatial panel models with provincial data from China from 2007 to 2016. The results indicate that all kinds of green spaces could decrease maternal mortality, wherein public green spaces may play a key role. In terms of spatial correlation, an increase in green space coverage in adjacent provinces may also result in a slight decline in maternal mortality. This paper provides valuable insight into the correlation between maternal health and green spaces.

Evaluation of resource utilization efficiency in obstetrics and gynecology units in China: A three-stage data envelopment analysis of the Shanxi province

In China, health care resources for expectant mothers and children are still not utilized to full efficiency, with health requirements still not being met. The purpose of this study is to critically examine the efficiency of gynecology and obstetrics hospital (OB/GYN) units in Shanxi province of China, with the overarching objective of exploring methods for improving their efficiency. We employ the three-stage data envelopment analysis (DEA) model to measure the efficiency of 134 OB/GYN units in Shanxi. The results show that the technical efficiency and scale efficiency scores of the sample units were low (0.48 and 0.54, respectively). The efficiency of the OB/GYN units varies by region, city, and county and by type of unit. We conclude that the main reason for the low efficiency of OB/GYN units in Shanxi province lies in the unreasonable scale. The government should, therefore, allocate health resources more reasonably, improving the efficiency of different regions, cities, and counties, as well as different types of OB/GYN units.

Role of Maternal Nutrition in the Health Outcomes of Mothers and Their Children: A Retrospective Analysis

BACKGROUND Low nutrition status of mothers plays an important role in increasing the prevalence of poor pregnancy outcomes. Poor pregnancy outcomes are the most common in the Guangzhou region of China. The objective of the study was to evaluate the role of maternal nutrition in the improvement of health outcomes for mothers and their children in the Guangzhou region of China. MATERIAL AND METHODS In this study, pregnancy medical records of women were analyzed. Data related to questionnaires which had been provided during hospital stays for nutritional consumption were gathered. Demographic characteristics and health outcomes of mothers and their children were recorded. Correlations of health outcomes with maternal nutrition were tested with respect to Z-scores at 95% confidence level. RESULTS Based on the health outcomes of mothers and their children, the study divided participants into 2 groups. The first group was mothers and their children with good health outcomes (live births with weighing ≥2.5 kg; the GHO group, n=130) and the second group was mothers and their children with poor health outcomes (miscarriage or premature birth with weighing less than 2.5 kg; the PHO group, n=70). These results showed positive correlation between financial status of the mother (salaried, P<0.001), maternal body mass index (P=0.001), maternal nutrition (P<0.001), maternal education (in years, P<0.001), and maternal age (P=0.004)) with health outcomes of mothers and their children. CONCLUSIONS The financial status of the mother, maternal nutrition, maternal age, and maternal education were the key determinants for predicting health outcomes of mothers and their children.

Analyzing maternal mortality rate in rural China by Grey-Markov model

Maternal mortality rate (MMR) in China has reduced during a decade but still higher than many countries around the world. Rural China is the key region which affects over all maternal death. This study aims to develop a suitable model in forecasting rural MMR and offer some suggestions for rural MMR intervention. Data in this study were collected through the Health Statistical Yearbook (2017) which included the overall MMR in China and urban and rural mortality rate. A basic grey model (GM(1,1)), 3 metabolic grey models (MGM), and a hybrid GM(1,1)-Markov model were presented to estimate rural MMR tendency. Average relative error (ARE), the post-test ratio (C), and small error probability (P) were adopted to evaluate models' fitting performance while forecasting effectiveness was compared by relative error.The MMR in rural China reduced obviously from 63.0 per 100,000 live births in 2005 to 21.1 per 100,000 live births in 2017. One basic GM(1,1) model was built to fit the rural MMR and the expression was X^((1)) (k + 1) = 553.80e^0.0947k - 550.00 (C = 0.0456, P > .99). Three MGM models expressions were X^((1)) (k + 1)  = 548.67e^0.0923k - 503.17 (C = 0.0540, P > .99), X^((1)) (k + 1) = 449.39e^0.0887k - 408.09 (C = 0.0560, P > .99), X^((1)) (k + 1) = 461.33e^0.0893k - 425.23(C = 0.0660, P > .99). Hybrid GM(1,1)-Markov model showed the best fitting performance (C = 0.0804, P > .99). The relative errors of basic GM(1,1) model and hybrid model in fitting part were 2.42% and 2.03%, respectively, while 5.35% and 2.08%, respectively, in forecasting part. The average relative errors of MGM were 2.07% in fitting part and 17.37% in forecasting part.Data update was crucial in maintain model's effectiveness. The hybrid GM(1,1)-Markov model was better than basic GM(1,1) model in rural MMR prediction. It could be considered as a decision-making tool in rural MMR intervention.

What has Iran achieved in under-five mortality in terms of equity and efficiency in the past decades?

OBJECTIVE

Iran has made remarkable progress in reducing child mortality over the past few decades. However, this promising profile is mainly average driven, and inequalities are not counted in judgments about the progress. In the present study, we used an achievement index approach to combine average and inequalities to provide a better picture of Iran's achievement in under-five mortality over the last two decades.

STUDY DESIGN

The study had a cross-sectional design.

METHODS

Data gathered in the two recent national demographic health surveys (DHSs) in 2000 and 2010 were used to conduct the analyses. Accordingly, 45,646 live births covered by DHS 2000 and 10,604 live births covered by DHS 2010 were investigated. An achievement index was constructed by incorporating some extensions to the concentration index, namely by incorporation of the average into the index.

RESULTS

The standard concentration index showed that under-five mortality was unequally distributed, hurting the poor, across all provinces and Iran overall in 2000 (concentration index = -0.1311 [standard error {SE} = 0.0139]) and 2010 (-0.1367 [SE = 0.0381]). The achievement index revealed that Iran has had achievements in under-five mortality (relative change in the mean has decreased from 29.5% to 25.8%), but the achievement was mostly due to reductions in the average mortality and not in its unequal distribution. The same result applied to a considerable number of provinces, and only a few have made achievements in both inequality and average.

CONCLUSIONS

Considering the lack of progress in the reduction of inequalities in under-five mortality over the past decades, equity-oriented policies should be of prime importance for Iran's healthcare system.

Inequality trends in the demographic and geographic distribution of health care professionals in China: Data from 2002 to 2016

China has long been negatively affected by a shortage and maldistribution of health workers. This study aimed to examine the national and regional trends in the demographic and geographic distribution inequality of health care professionals in China from 2002 to 2016. Based on data from the China Health and Family Planning Statistical and China Statistical Yearbooks, we calculated the Gini coefficient and the Theil T and Theil L indices based on the number of health care professionals per capita and per geographic area to measure the inequalities in their demographic and geographic distribution, respectively. The contributions by intra-regional and inter-regional differences on total inequality were explored within and among East, Central, and West China via Theil index decomposition. We found that the national demographic distribution of health care professionals maintained in an absolute equality level, and the inequality indices decreased gradually, whereas the corresponding geographic inequalities were severe and presented a worsening trend. Compared with nurses, physicians not only maintained higher densities but also maintained a more equal distribution. Intra-regional disparities within the east, central, and western regions were the main cause for overall demographic inequality, whereas both intra-regional and inter-regional disparities significantly contributed to overall geographic inequality. To conclude, the distribution equality of health care professionals by population was satisfactory, whereas the corresponding distribution inequality by area was severe. Different types of distribution inequality of health care professionals existed regionally and nationally despite their increasing quantities and densities. Factors beyond population size should be considered when the government introduces health workforce allocation policies.