Giving birth at a health-care facility in rural China: is it affordable for the poor?

Trends in out-of-pocket expenditure on facility-based delivery and financial protection of health insurance: findings from Vietnam's Household Living Standard Survey 2006-2018

Much of the existing empirical literature on the association between health insurance and out-of-pocket (OOP) expenditures on facility-based delivery in low- and middle-income countries is cross sectional in nature. Comparatively little is known about the dynamic shifts in OOP expenditures and the health insurance nexus. Using seven biennial waves of Vietnam's Household Living Standard Survey covering the period 2006-2018 and a generalized linear model this study examines trends in OOP expenditures on facility-based delivery and financial protection afforded by Vietnam's social health insurance system. Over the period under consideration, the pattern of health facility utilization among the insured shifted steadily from commune health centers towards higher-level government hospitals. Real OOP for delivery was 52.7% higher in 2018 than in 2006-2008 and insurance reduced OOP expenditures by 28.5%. Compared to district hospitals, giving birth at higher-level government hospitals increased OOP expenditures by 72.3% while giving birth at commune health centers reduced OOP expenditures by 55.7%. Additional analysis involving interactions between insurance status, types of public health facility and year dummies suggested a drop in financial protection of insurance, from 48% to 26.9% among women delivering at district hospitals and from 31.2 to 18.7% among those delivering at higher-level government hospitals. The modest financial protection of health insurance and its declining trend calls for policy measures that would strengthen the quality of maternal care at primary care institutions, strengthen financial protection and curb the provision of two-tiered clinical services and charges.

The magnitude of out-of-pocket expenditure for antenatal care in low and middle-income countries: A systematic review and meta-analysis

BACKGROUND

Owing to the lack of compiled global evidence on out-of-pocket expenditure (OOPE) for antenatal care (ANC), this systematic review and meta-analysis estimated the magnitude of OOPE for ANC in low and middle-income countries (LMICs).

METHODS

An electronic search was conducted using 10 databases and a hand search of the eligible studies' reference lists. Studies on OOPE for ANC in LMICs, published in English without time restriction, were included. The comparability of OOPE values was improved using inflation and exchange rate adjustment to the year 2019. Random-effects meta-analysis was performed to generate pooled estimates.

RESULTS

Among the 9766 articles retrieved, 32 were selected. Only 13/137 (9.5%) countries reported evidence of OOPE during pregnancy in LMICs. The majority of the studies (n = 2779.4%) were from lower-middle-income settings. Ten (31.3%) studies from African region, 21 (65.6%) studies from South-East-Asian region, 1 (3.1%) study from region of Americas and none from the other regions were included. The average OOPE for ANC and single ANC visit ranged from United States Dollar (USD) 2.41 to USD 654.32 in LMICs, the lowest in Tanzania and the highest in India. The pooled OOPEs were USD 63.29 (95% confidence interval [CI] = 51.93-74.65) and USD 12.93 (95%CI = 4.54-21.31) for ANC and single ANC visit in LMICs, respectively.

CONCLUSION

The study revealed that the pooled estimates of OOPE for ANC throughout pregnancy and per visit were high in some countries, with a wide variability observed across countries. There was a lack of evidence on OOPE for ANC from many LMICs, and filling the evidence gap in LMICs is highlighted.

Changes in caesarean section rates in China during the period of transition from the one-child to two-child policy era: cross-sectional National Household Health Services Surveys

OBJECTIVES

Since 2009, China has introduced policies, principally targeting health professionals, to reduce caesarean section (CS) overuse. In 2016, China endorsed a universal two-child policy. Advanced maternal age and previous CS may indicate changes in obstetric risks, which raise concerns on the need for and safety of CS. This study investigated changes in CS rates in 2008-2018, and factors associated with CS use during the period of transition from the one-child to two-child policy era.

DESIGN

We used births data from the cross-sectional National Household Health Services Surveys in 2013 and 2018.

SETTING

Population-based national survey.

PARTICIPANTS

Women who had the last live birth within 5 years before the survey.

PRIMARY OUTCOME MEASURE

CS rate.

RESULTS

Overall CS use increased from 40.9% in 2008 to 47.2% in 2014 with significant increase in rural areas and the western region, and slightly decreased to 45.2% in 2018 with the greatest decrease among nulliparous women. Maternal request for CS by urban nulliparous women decreased from 36.8% in 2008-2009 to 22.2% in 2016-2018, but this change was not statistically significant in rural areas. Maternal age over 35 years old (OR 2.40, 95% CI 1.72 to 3.35) and births that occurred at a private hospital (OR 1.52, 95% CI 1.25 to 1.86) were associated with CS use among nulliparous women in 2016-2018. The CS rate among multiparous women increased over time. Individual socioeconomic factors associated with CS use among multiparous women.

CONCLUSIONS

The CS rate rise in China in 2008-2018 is attributable to increased use in rural areas and the less developed western region. The population policy shift, alongside facility policies for unnecessary CS reduction, are likely factors in CS reduction in urban areas. The challenge remains to reduce unnecessary CS, at the same time as providing safe, universal access to CS for women in need.

Maternal mortality ratio in China from 1990 to 2019: trends, causes and correlations

Background

Maternal mortality ratio is an important indicator to evaluate the health status in developing countries. Previous studies on maternal mortality ratio in China were limited to certain areas or short periods of time, and there was a lack of research on correlations with public health funding. This study aimed to assess the trends in the maternal mortality ratio, the causes of maternal death, and the correlations between maternal mortality ratio and total health financing composition in China from 1990 to 2019.

Methods

Data in this longitudinal study were collected from the China Health Statistics Yearbooks (1991–2020) and China Statistical Yearbook 2020. Linear regression analysis was used to assess the trends in the maternal mortality ratio in China. Pearson correlation analysis was used to assess the correlations between national maternal mortality ratio and total health financing composition.

Results

The yearly trends of the national, rural and urban maternal mortality ratio were − 2.290 (p < 0.01), − 3.167 (p < 0.01), and − 0.901 (p < 0.01), respectively. The gap in maternal mortality ratio between urban and rural areas has narrowed. Obstetric hemorrhage was the leading cause of maternal death. The mortalities ratios for the main causes of maternal death all decreased in China from 1990 to 2019. The hospital delivery rate in China increased, with almost all pregnant women giving birth in hospitals in 2019. Government health expenditure as a proportion of total health expenditure was negatively correlated with the maternal mortality ratio (r = − 0.667, p < 0.01), and out-of-pocket health expenditure as a proportion of total health expenditure was positively correlated with the maternal mortality ratio (r = 0.516, p < 0.01).

Conclusion

China has made remarkable progress in improving maternal survival, especially in rural areas. The maternal mortality ratio in China showed a downward trend over time. To further reduce the maternal mortality ratio, China should take effective measures to prevent obstetric hemorrhage, increase the quality of obstetric care, improve the efficiency and fairness of the government health funding, reduce income inequality, and strengthen the medical security system.

Effects of Clinical Pathways on Cesarean Sections in China: Length of Stay and Direct Hospitalization Cost Based on Meta-Analysis of Randomized Controlled Trials and Controlled Clinical Trials

The cesarean section (CS) on maternal request increased sharply in China, bringing pressure to medical resources and national insurance. We assessed the use of clinical pathways (CPWs) for CS compared with conventional medical care by outcomes of length of stay (LOS) in hospital and direct hospitalization cost (DHC). Four Chinese electronic databases, including China National Knowledge Infrastructure (CNKI), Wanfang, CQVIP, and SinoMed, were explored to December 2020 for the full-text papers published in Chinese. Literature that quantitatively assessed the effects of CPW on LOS or DHC were eligible for inclusion. The weighted mean differences (WMDs) were pooled. Twenty-five articles were included in our analysis, with a total sample of 7761 women. These studies were performed from 2004 to 2017 and reported from 2005 to 2018. The synthesized results showed a shorter LOS (in days) (WMD = −1.37, 95% CI: −1.48 to −1.26) and a less DHC (CNY¥) (WMD = −520.46, 95% CI: −554.06 to −503.63) in the CPW group, comparing with that of conventional care. With the need for CS on the rise, the introduction of CPW could effectively reduce LOS and DHC, thereby releasing the medical resources and insurance pressure.

Cesarean delivery rates, costs and readmission of childbirth in the new cooperative medical scheme after implementation of an episode-based bundled payment (EBP) policy

BACKGROUND

In the past decade, the rate of cesarean delivery increased dramatically in rural China under the fee-for-service (FFS) system. In September 2011, the New Cooperative Medical Scheme (NCMS) agency in Yong'an county in Fujian province of China adopted a policy of reforming payment for childbirth by transforming the FFS payment into episode-based bundled payment (EBP), which made the cesarean deliveries less profitable. Thus, this study was conducted to determine the effect of EBP policy on reducing cesarean use and controlling delivery costs for rural patients in the NCMS.

METHODS

Data from the inpatient information database of the NCMS agency from January 2010 to March 2013 was collected, in which Yong'an county was employed as a reform county and 2 other counties as controls. We investigated the effects of EBP on cesarean delivery rate, costs of childbirth and readmission for rural patients in the NCMS using a natural experiment design and difference in differences (DID) analysis method.

RESULTS

The EBP reform was associated with 33.97% (p<0.01) decrease in the probability of cesarean delivery. The EBP reform, on average, reduced the total spending per admission, government reimbursement expenses per admission, and out-of-pocket (OOP) payments per admission by ¥ 649.61, ¥ 575.01, and ¥ 74.59, respectively. The OOP payments had a net decrease of 14.24% (p<0.01); whereas the OOP payments as a share of total spending had a net increase of 8.72% (p<0.01). There was no evidence of increase in readmission rates.

CONCLUSIONS

These results indicate that the EBP policy has achieved at least a short-term success in lowering the increase of cesarean delivery rate and costs of childbirth. Considering both the cesarean rate and the OOP payments as a share of total spending after the reform were still high, China still has a long way to go to achieve the ideal level of cesarean rate and improve the benefits of deliveries for rural population.

Commercialization of obstetric and neonatal care in the Democratic Republic of the Congo: A study of the variability in user fees in Lubumbashi, 2014

OBJECTIVE

In the Democratic Republic of the Congo, insufficient state financing of the health system produced weak progress toward targets of Millennium Development Goals 4 and 5. In Lubumbashi, almost all women pay out-of-pocket for obstetric and neonatal care. As no standard pricing system has been implemented, there is great variation in payments related to childbirth between health facilities and even within the same facility. This work investigates the determinants of this variation.

METHODS

We conducted a cross-sectional study including women from admission through discharge at 92 maternity wards in Lubumbashi in March 2014. The women's payments were collected and validated by triangulating interviews of new mothers and nurses with document review. We studied payments related to delivery from the perspective of women delivering. The total was the sum of the payments linked to seeking and accessing care and transport of the woman and companion. The determinants were assessed by multilevel regression.

RESULTS

Median payments for delivery varied by type: for an uncomplicated vaginal delivery, US$45 (range, US$17-260); for a complicated vaginal delivery US$60 (US$16-304); and for a Cesarean section, US$338 (US$163-782). Vaginal delivery was more expensive at health centers than in general referral hospitals or polyclinics. Cesarean sections done in corporate polyclinics and hospitals were more expensive than those done in the general referral hospitals. Referral of delivering women, use of more highly trained personnel, and a longer stay in the maternity unit contributed to higher expenses. A vaginal delivery in the private sector was more cost-effective than in the public sector.

CONCLUSION

To guarantee universal coverage of high-quality care, we suggest that the government and funders in DRC support health insurance and risk pool initiatives, and introduce and institutionalize free mother and infant care.

Onsite midwife-led birth units (OMBUs) for care around the time of childbirth: a systematic review

Introduction

To ensure timely access to comprehensive emergency obstetric care in low- and middle-income countries, a number of interventions have been employed. This systematic review assesses the effects of onsite midwife-led birth units (OMBUs) embedded within hospitals which provide comprehensive emergency obstetric and newborn care.

Methods

Both interventional and observational studies that compared OMBUs with standard medical-led obstetric care were eligible for inclusion. Cochrane Central Register of Controlled Trials, PubMed/Medline, EMBASE, CINAHL, Science Citation and Social Sciences Citation Index, Global Health Library and one Chinese database were searched. Meta-analysis was conducted to synthesise data from randomised controlled trials (RCTs). Findings of observational studies were summarised by forest plots with brief narratives.

Results

Three RCTs, one controlled before-and-after study and six cohort studies were included. There were no or very few maternal and perinatal deaths in either OMBUs or standard obstetric units, with no significant differences between the two. Women giving birth in OMBUs were less likely to use epidural analgesia (risk ratio (RR) 0.67, 95% CI 0.55 to 0.82; three trials, n=2431). The UK national cohort study and two other cohorts in China and Nepal found less oxytocin augmentation, more spontaneous vaginal deliveries, fewer caesarean sections and fewer episiotomies performed in OMBUs than in standard obstetric units. These differences were not statistically significant in RCTs and the remaining cohorts. One study investigated satisfaction with midwife-led birth care among women and midwives, with positive findings in both groups favouring OMBUs. In addition, two studies found that the total cost of birth was lower in OMBUs than in standard obstetric units.

Conclusions

OMBUs could be an alternative model for providing safe and cost-effective childbirth care, which may be particularly important in low- and middle-income countries to meet the growing demand for facility-based birth for low-risk women and improve efficiency of health systems.

Survey of Obstetric Care and Cesarean Delivery Rates in Shanghai, China

BACKGROUND

China has one of the highest cesarean delivery rates in the world, with most cesareans done without indication.

METHODS

Observation of how perinatal care is delivered in a range of Shanghai hospitals was done to gain insight into the 50 percent cesarean delivery rate. A mixed methods approach combined a descriptive structured survey of obstetric services with standardized interview with obstetricians and qualitative observation of obstetric services in six different Shanghai obstetric facilities.

RESULTS

The volume was extremely high: physicians in public hospitals routinely saw up to 80-120 prenatal patients per day. Frequent prenatal testing substituted for time spent in patient-doctor interactions. Family members were not allowed in delivery wards where women labored alone. Obstetrics services had low levels of nursing support and anesthesia for labor. Physical space favored rapid surgical turnover over longer labor. Physicians reported practical incentives to perform cesarean sections.

DISCUSSION

Cesarean delivery was an efficient way to move patients through the systems observed, given the staffing and physical limitations of the public facilities. Physicians reported that patients and families perceived cesarean delivery as safer. Physicians also reported fear of charges of malpractice, for which they might be found to be financially liable or in physical danger. Societal expectations are high, and in a "one child" society, perception that cesarean section was safer may also have driven cesarean rates. Given the end of the One Child Policy, the preference for cesarean delivery may change.

Comparing Maternal Services Utilization and Expense Reimbursement before and after the Adjustment of the New Rural Cooperative Medical Scheme Policy in Rural China

Background

The New Rural Cooperative Medical Scheme (NCMS) includes a maternal care benefits package that is associated with increasing maternal health services. The local compensation policies have been frequently adjusted in recent years. This study examined the association between the NCMS maternal-services policy adjustment and expense reimbursement in Yuyao, China.

Methods

Two household surveys were conducted in Yuyao in 2008 and 2011 (before and after the NCMS policy adjustment, respectively). Local women (N = 154) who had delivery history in the past three years were recruited. A questionnaire was used to collect information about delivery history, maternal health services utilization (prenatal care, postnatal care, and the grade of delivery institutions), NCMS participation, and reimbursement status. Logistic regression analyses were used to predict the association between policy adjustment and maternal health utilization and the association between policy adjustment and out-of-pocket proportion. Next, t-tests and covariance analyses adjusting for household income were used to compare the out-of-pocket proportion between 2008 and 2011.

Results

Results revealed that compensation policy adjustment was associated with an increase in postnatal visits (adjusted OR = 3.32, p = 0.009) and the use of second level or above institutions for delivery (adjusted OR = 2.32, p = 0.03) among participants. In 2008, only 9.1% of pregnant women received reimbursement from the NCMS; however, this rate increased to 36.8% in 2011. After policy adjustment, there were no significant changes in the proportion of out-of-pocket expenses shared in delivery fee (F = 0.24, p = 0.63) and in household income (F = 0.46, p = 0.50).

Conclusions

Financial compensation increase improved maternal health services utilization; however, this effect was limited. Although the reimbursement rate was raised, the out-of-pocket proportion was not significant changed; therefore, the compensation design scheme must be adjusted in practice.

Influencing factors associated with the mode of birth among childbearing women in Hunan Province: a cross-sectional study in China

BACKGROUND

An unnecessary Caesarean section (CS) can cause increased maternal and perinatal morbidity and other adverse short- and long-term outcomes. However, countries worldwide have witnessed an increasing trend toward the use of CS. Our objectives were to explore the influencing factors associated with the mode of birth among childbearing women in Hunan Province and to provide evidence and suggestions for the improvement and further understanding of vaginal birth (VB) in China.

METHODS

A total of 977 childbearing women (375 pregnant women and 602 mothers of infants) were enrolled in this study using a two-stage cluster sampling method, and a self-administered questionnaire was used to collect data relating to the mode of birth. A t-test and χ (2)-test were used to analyse the differences between groups, and logistic regression analysis was used to explore the factors that influenced the mode of birth.

RESULTS

The VB ratio was 46.2 %, while the CS ratio was 53.8 % in Hunan Province. Among women whose preference was VB, only 69.4 % gave birth by VB. Among women whose preference was CS, 98.1 % gave birth by CS. The top four reasons for preferring CS were a lack of confidence in VB (37.3 %), an abnormality in the prenatal examination (36.6 %), the notion that the baby would suffer fewer risks (34.8 %) and the fear of pain from VB (32.7 %). Age, prenatal examination, and doctors' suggestion were significantly associated with women's mode of birth preference, while place of household registration, husband's preference, prenatal examination and doctors' suggestion had a significant influence on women who changed their choice from VB to CS.

CONCLUSIONS

The percentage of CS in Hunan was extremely high. Medical factors, such as abnormalities in prenatal examinations, and non-medical factors, such as a lack of confidence in VB, the fear of pain during VB, the desire to select the time of birth and healthy birth systems, should be seriously considered. Targeted health promotion interventions should be implemented to improve the performance of VB.

Caesarean section rates in Mozambique

BACKGROUND

The Caesarean section (C-section) rate is used as an indicator for availability and utilization of life-saving obstetric services. The purpose of the present study was to explore changes in C-section rates between 1995 and 2011 by area, place of delivery and maternal socioeconomic factors in Mozambique.

METHODS

Cross-sectional data from the Demographic and Health Surveys conducted in Mozambique in 1997, 2003 and 2011 were used, including women having a live birth within 3 years prior to the survey. Descriptive statistics and logistic regressions were used to identify factors associated with having a C-section.

RESULTS

The C-section rate decreased slightly from 2.5% in 1995-1997 to 2.1% in 2001-2003 and then increased to 4.7% in 2009-2011. In 2009-2011, C-section rates ranged in urban areas from 4.6% in the northern region to 12.2% in the southern region and in rural areas from 1.6% in the northern region to 3.9% in the southern region. 12.3% of the richest women had had a C-section, compared to 1.7% of the poorest women. C-sections were the most common at public hospitals (12.6% in 2009-2011), but C-sections at health centers increased from the second to the third period. The likelihood of having a C-section was associated with living in urban areas and in the southern region, having a formal education and living in a rich household, even adjusting for age and parity (and study periods). The strongest relationship was for the richest household wealth quintile [OR (95% CI): 9.8 (6.3-15.3)]. The highest rate (20.6%) was found among the richest women giving birth at public hospitals in the southern region in 2009-2011.

CONCLUSION

In Mozambique, underuse of C-section was likely among the poor and in rural areas, but overuse in the most advantaged groups seemed to be emerging.

Maternal health care seeking by rural Tibetan women: characteristics of women delivering at a newly-constructed birth center in western China

Background

Increasing skilled birth attendance at delivery is key to reducing maternal mortality, particularly among marginalized populations. Despite China’s successful rollout of a national policy to promote facility deliveries, challenges remain among rural and ethnic minority populations. In response, a Tibetan Birth and Training Center (TBTC) was constructed in 2010 to provide high-quality obstetric care in a home-like environment to a predominantly Tibetan population in Tso-ngon (Qinghai) province in western China to improve maternal care in the region. This study examines if and how first users of the TBTC differ from women in the broader community, and how this information may inform subsequent maternal health care interventions in this area.

Methods

Trained, Tibetan interviewers administered a face-to-face, quantitative questionnaire to two groups of married, Tibetan women: women who had delivered at the TBTC between June 2011-June 2012 (n = 114) and a non-equivalent comparison group of women from the same communities who had delivered in the last two years, but not at the TBTC (n = 108). Chi-squared and ANOVA tests were conducted to detect differences between the samples.

Results

There were no significant differences between the samples in education or income; however, women from the TBTC sample were significantly younger (25.55 vs. 28.16 years; p < 0.001) and had fewer children (1.54 vs. 1.70; p = 0.05). Items measuring maternity health care-seeking and perceived importance of health facility amenities indicated minimal differences between the samples. However, as compared to the community sample, the TBTC sample had a greater proportion of women who reported having the final say regarding where to deliver (26 % vs. 14 %; p = 0.02) and having a friend or family member who delivered at home (50 % vs. 28 %; p < 0.001).

Conclusions

Findings did not support the hypothesis that the TBTC attracts lower-income, less-educated women. Minimal differences in women's characteristics and perceptions regarding delivery care between the two samples suggest that the TBTC is serving a broad cross-section of women. Differences between the samples with respect to delivery care decision-making and desire for skilled birth care underscore areas that may be further explored and supported in subsequent efforts to promote facility delivery in this population, and similar populations, of women.

The quality of childbirth care in China: women's voices: a qualitative study

BACKGROUND

In the context of improved utilisation of health care and outcomes, rapid socio-economic development and health system reform in China, it is timely to consider the quality of services. Data on quality of maternal health care as experienced by women is limited. This study explores women's expectations and experiences of the quality of childbirth care in rural China.

METHODS

Thirty five semi-structured interviews and five focus group discussions were conducted with 69 women who had delivered in the past 12 months in hospitals in a rural County in Anhui Province. Data were transcribed, translated and analysed using the framework approach.

RESULTS

Hospital delivery was preferred because it was considered safe. Home delivery was uncommon and unsupported by the health system. Expectations such as having skilled providers and privacy during childbirth were met. However, most women reported lack of cleanliness, companionship during labour, pain relief, and opportunity to participate in decision making as poor aspects of care. Absence of pain relief is one reason why women may opt for a caesarean section.

CONCLUSIONS

These findings illustrate that to improve quality of care it is crucial to build accountability and communication between providers, women and their families. Ensuring women's participation in decision making needs to be addressed.

Effective reimbursement rates of the rural health insurance among uncomplicated tuberculosis patients in China

OBJECTIVE

China has established universal health coverage for 830 million rural residents through the rapid expansion of the New Cooperative Medical Scheme (NCMS). This study accesses the effective reimbursement rates of NCMS among patients with tuberculosis (TB) who lived in counties where their schemes covered costs within TB dispensaries and those who did not.

METHODS

We randomly selected 50 patients with uncomplicated TB from each of the eight counties in two provinces. We reviewed all patient clinical charts and conducted face-to-face surveys. Effective reimbursement was measured as the proportion of patients who received reimbursement from NCMS and the average reimbursement rate of total medical costs.

RESULTS

A total of 393 patients with TB were included with 186 from Zhejiang and 206 from Sichuan. In the covered group, only 41% of patients with TB received reimbursements for medical costs in TB dispensary in Zhejiang as compared to 84% in Sichuan, because patients in Zhejiang needed to keep their bills and claim later, while Sichuan had patient medical costs automatically deducted at the point of care. Patients in the covered group had a significantly higher average reimbursement rate compared with those in the uncovered group (13% vs. 8% in Zhejiang and 17% vs. 12% in Sichuan). For all patients, the biggest cost was due to hospitalisation, and their overall reimbursement rates were low.

CONCLUSION

New Cooperative Medical Scheme has not relieved the financial burden of TB-related medical costs. NCMS should cover costs in TB dispensaries. Measures are also needed to minimise unnecessary hospitalisation, and lower the barriers to claims.

Cesarean section in the People's Republic of China: current perspectives

OBJECTIVE

To review the current knowledge on the prevalence, reasons, and consequences of cesarean sections in the People's Republic of China.

METHODS

Peer-reviewed articles were systematically searched on PubMed. The following Chinese databases were comprehensively searched: the China National Knowledge Infrastructure, Wanfang, and the VIP information. The databases were searched from inception to September 1, 2013. Two reviewers independently screened the titles and abstracts for eligibility. Full texts of eligible papers were reviewed, where relevant references were hand-searched and reviewed.

FINDINGS

Sixty articles were included from PubMed, 17 articles were intentionally picked out from Chinese journals, and five additional articles were added, for a total of 82 articles for the analysis. With a current national rate near 40%, the literature consistently reported a rapid rise of cesarean sections in the People's Republic of China in the past decades, irrespective of where people lived or their socioeconomic standing. Nonclinical factors were considered as the main drivers fueling the rise of cesareans in the People's Republic of China. There was a lively debate on whether women's preferences or providers' distorted financial incentives affected the rise in cesarean sections. However, recent evidence suggests that it might be the People's Republic of China's health development approach - focusing on specialized care and marginalizing primary care - that is playing a role. Although 30 articles were identified studying the consequences of cesareans, the methodologies are in general weak and the themes are out of focus.

CONCLUSION

The overuse of cesareans is rising alarmingly in the People's Republic of China and has become a real public health problem. No consensus has been made on the leverage factors that drive the cesarean epidemic, particularly for those nonclinical factors. The more macro level structural factors may have played a part, though further research is warranted to understand the mechanisms. Knowledge of the consequences of cesareans, particularly for women, is limited in the People's Republic of China, leaving a substantial literature gap.

Changes in health expenditures in China in 2000s: has the health system reform improved affordability

Background

China's health system reform launched in early 2000s has achieved better coverage of health insurance and significantly increased the use of healthcare for vast majority of Chinese population. This study was to examine changes in the structure of total health expenditures in China in 2000–2011, and to investigate the financial burden of healthcare placed on its population, particularly between urban and rural areas and across different socio-economic development regions.

Methods

Health expenditures data came from the China National Health Accounts study in 1990–2011, and other data used to calculate the financial burden of healthcare were from China Statistical Yearbook and China Population Statistical Yearbook. Total health expenditures were divided into government and social expenditure, and out-of-pocket payment. The financial burden of healthcare was estimated as out-of-pocket payment per capita as a percentage of annual household living consumption expenditure per capita.

Results

Between 2000 and 2011, total health expenditures in China increased from Chinese yuan 319 to 1888 (United States dollars 51 to 305), with average annual increase of 17.4%. Government and social health expenditure increased rapidly being 22.9% and 18.8% of average annual growth rate, respectively. The share of out-of-pocket payment in total health expenditure for the urban population declined from 53% in 2005 to 36% in 2011, but had only a slight decrease for the rural population from 53% to 50%. Out-of-pocket payment, as a percentage of annual household living consumption, has continued to rise, particularly in the rural population from the less developed region (6.1% in 2000 to 8.8% in 2011).

Conclusions

The rapid increase of public funding to subsidize health insurance in China, as part of the reform strategy, did not mitigate the out-of-pocket payment for healthcare over the past decade. Financial burden of healthcare on the rural population increased. Affordability among the rural households with sick members, particularly in the less developed region, is getting worse. It needs effective measures on cost control including healthcare provider payment reform and well developed health insurance schemes to offer better financial protection for the vulnerable Chinese seeking essential healthcare.

Engaging sub-national governments in addressing health equities: challenges and opportunities in China's health system reform

China's current health system reform (HSR) is striving to resolve deep inequities in health outcomes. Achieving this goal is difficult not only because of continuously increasing income disparities in China but also because of weaknesses in healthcare financing and delivery at the local level. We explore to what extent sub-national governments, which are largely responsible for health financing in China, are addressing health inequities. We describe the recent trend in health inequalities in China, and analyse government expenditure on health in the context of China's decentralization and intergovernmental model to assess whether national, provincial and sub-provincial public resource allocations and local government accountability relationships are aligned with this goal. Our analysis reveals that government expenditure on health at sub-national levels, which accounts for ∼90% of total government expenditure on health, is increasingly regressive across provinces, and across prefectures within provinces. Increasing inequity in public expenditure at sub-national levels indicates that resources and responsibilities at sub-national levels in China are not well aligned with national priorities. China's HSR would benefit from complementary measures to improve the governance and financing of public service delivery. We discuss the existing weaknesses in local governance and suggest possible approaches to better align the responsibilities and capacity of sub-national governments with national policies, standards, laws and regulations, therefore ensuring local-level implementation and enforcement. Drawing on China's institutional framework and ongoing reform pilots, we present possible approaches to: (1) consolidate key health financing responsibilities at the provincial level and strengthen the accountability of provincial governments, (2) define targets for expenditure on primary health care, outputs and outcomes for each province and (3) use independent sources to monitor and evaluate policy implementation and service delivery and to strengthen sub-national government performance management.

High Caesarean section rate in rural China: is it related to health insurance (New Co-operative Medical Scheme)?

The epidemic of Caesarean section (CS) is worldwide, and it has been argued that it is mainly due to non-medical factors, including healthcare financing patterns. We investigated the use of CS in rural China and the related factors, particularly health insurance in the form of the New Co-operative Medical Scheme introduced in 2003. A cross-sectional survey of women who gave birth in 2008-2009 was conducted in five rural counties in central and western China. Of the 5049 new mothers, 73% were interviewed. The association between health insurance coverage and self-reported CS (divided into emergency and non-emergency CS) were examined by cross-tabulation and logistic regression, adjusting for maternal age, education, occupation, household income, previous abortions, parity and type of birth health facility. We found that 46% of all births (3550) were CSs, with 13% having an emergency and 33% a non-emergency CS. Women reported that half of the non-emergency CSs were recommended by a doctor and half were requested by themselves. In those counties with mid-range CS rates (28%-63%), health insurance coverage was associated with having CS, and particularly with having non-emergency CS. In those counties with the highest (82%) and lowest (13%) rate, there was no statistically significant association. The findings suggest that health insurance coverage may have facilitated the overuse of CS. Further studies are needed to develop appropriate interventions to reduce non-medically indicated CS, focussing on payment mechanisms, healthcare provider practice patterns, and maternal requests.

China's facility-based birth strategy and neonatal mortality: a population-based epidemiological study

BACKGROUND

China's success in improving the quality of and access to obstetric care in hospitals offers an opportunity to examine the effect of a large-scale facility-based strategy on neonatal mortality. We aimed to establish this effect by assessing how the institutional strategy of intrapartum care has affected neonatal mortality and its regional inequalities.

METHODS

We did a population-based epidemiological study of China's National Maternal and Child Mortality Surveillance System from 1996 to 2008. We used data from 116 surveillance sites in China (37 urban districts and 79 rural counties) to examine neonatal mortality by cause, socioeconomic region, and place of birth, with Poisson regression to calculate relative risks. Rural counties were categorised into types 1-4, with type 4 being the least developed. We report attributable risks and preventable fractions for hospital births versus home births.

FINDINGS

Neonatal mortality decreased by 62% between 1996 and 2008. The rate of neonatal mortality was much lower for hospital births than for home births in all regions, with relative risks (RR) ranging from 0·30 (95% CI 0·22-0·40) in type 2 rural counties, to 0·52 (0·33-0·83) in type 4 counties (p<0·0001). The proportion of neonatal deaths prevented by hospital birth ranged from 70% (95% CI 59·7-77·8) to 48% (16·9-67·3). Babies born in urban hospitals had a low rate of neonatal mortality (5·7 per 1000 livebirths); but those born in hospitals in type 4 rural counties were almost four times more likely to die than were children born in urban hospitals (RR 3·80, 2·53-5·72).

INTERPRETATION

Other countries can learn from China's substantial progress in reducing neonatal mortality. The major effect of China's facility-based strategy on neonatal mortality is much greater than that reported for community-based interventions. Our findings will provide a great impetus for countries to increase demand for and quality of facility-based intrapartum care.

FUNDING

China Medical Board, UNICEF China.

Factors influencing rising caesarean section rates in China between 1988 and 2008

OBJECTIVE

To identify factors driving the rapid increase in caesarean section in China between 1988 and 2008.

METHODS

Data from four national cross-sectional surveys (1993, 1998, 2003 and 2008) and modified Poisson regression were used to determine whether changes in household income, access to health insurance or women's education accounted for the rise in caesarean sections in urban and rural areas.

FINDINGS

In 2008, 64.1% of urban women and 11.3% of women in the poorest rural region reported giving birth by caesarean section. A fast rise was occurring in all socioeconomic groups. Between 1993 and 2008, the risk of caesarean section had increased more than threefold in urban areas (relative risk, RR: 3.63; 95% confidence interval, CI: 2.61-5.04) and more than 15-fold in rural areas (RR: 15.46; 95% CI: 10.46-22.86). After adjustment for improvements in income, education and access to health insurance over the study period, the RR dropped minimally in urban areas (RR: 3.07; 95% CI: 2.32-4.07), which suggests that these factors do not explain the rise; in rural areas, the adjusted RR dropped to 7.18 (95% CI: 4.82-10.69), which shows that socioeconomic change is only partly responsible for the rise. Socioeconomic region of residence was a more important driver of the caesarean section rate than individual socioeconomic status.

CONCLUSION

The large variation in caesarean section rate by socioeconomic region--independent of individual income, health insurance or education--suggests that structural factors related to service supply have influenced the increasing rate more than a woman's ability to pay.

Socioeconomic inequalities in hospital births in China between 1988 and 2008

OBJECTIVE

To assess trends in hospital births in China during 1988-2008 in an effort to determine if efforts to overcome financial barriers to giving birth in hospital have reduced the access gap between the rich and the poor.

METHODS

Cross-sectional data obtained from four National Health Service Surveys were used to determine trends in hospital births during 1988-2008. Crude and adjusted annual rates were calculated by means of Poisson regression and were used to define trends across socioeconomic regions and households in different income quintiles.

FINDINGS

In 2008 women throughout China were giving birth in hospital almost universally except in region IV, the most remote rural region, where the percentage of hospital births was only 60.8. Hospital births in this region had increased steadily before 2002, but after that year the upward trend slowed down. During 1988-2001 the average yearly increase had been 21%, but in 2002-2008 it dropped to 10% (P = 0.0031). Inequalities between socioeconomic regions were greater than among individual households belonging to different income strata. By 2008 the difference between low- and high-income households in the proportion of hospital births had become very small (96.1% and 87.7% of high- and low-income households, respectively, gave birth in hospital that year).

CONCLUSION

Most Chinese women now give birth in hospital, but the poorest rural region is still lagging behind. A more active and comprehensive approach will be needed to increase hospital births in these remote, hard-to-reach populations.