Elsevier

The Lancet

Volume 378, Issue 9801, 22–28 October 2011, Pages 1493-1500
The Lancet

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

https://doi.org/10.1016/S0140-6736(11)61096-9Get rights and content

Summary

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.

Introduction

Millennium Development Goal 4 has encouraged efforts to reduce child mortality. Substantial decreases in deaths in children younger than 5 years old have been due mostly to reductions in postneonatal mortality.1 No similar progress has been made in the reduction of neonatal mortality, and wide disparities in mortality of neonates persist between and within countries.1 The most effective interventions for reducing neonatal mortality are well established2, 3, 4 and consensus has been reached for the scaling-up of the continuum of care.5 However, how communities can be practically engaged in the home-to-hospital continuum is unclear and debate continues about the best strategy to deliver the life-saving interventions.5, 6

Although intrapartum risk factors are probably the greatest threat to neonatal survival7 and facility-based birth care by a skilled provider can prevent many neonatal deaths,2, 3, 4 an institutional strategy for intrapartum care might not be considered as an immediate option for poor countries. Therefore, attention in these countries has focused mainly on the effectiveness of community and outreach interventions in reducing neonatal mortality.8, 9, 10, 11 Much less is known about the effect of large-scale facility-based strategies on neonatal survival.4 China's extensive experience in promoting hospital-based birth can contribute information about the effect of such strategies. China is unusual among developing nations because its rate of decline in neonatal mortality since 1990, is roughly the same as that in postneonatal mortality.1, 12 Historically, child mortality was much lower in China than in many countries of similar economic development,13 which can be attributed to its focus on primary health care during the 1960s and 1970s.14 However, with the economic reforms since 1978, numbers of community-financed, barefoot doctors decreased dramatically, community health care was privatised, and access to health care relied heavily on user charges.14, 15, 16

Since 2000, community midwifery has been discouraged in China, and a safe motherhood programme that encourages hospital delivery introduced.17, 18, 19, 20 Demand for and quality of hospital services was improved with the strengthening of infrastructure, staff training and supervision in township and low-level hospitals, establishment of referral channels to tertiary hospitals with capacity to deal with emergency obstetric care, and the provision of subsidies to families and hospitals to encourage hospital delivery.17, 18, 19, 20 In 1988, less than half of all women in China gave birth in hospital, but only 20 years later, hospital births have become almost universal.18 Economic inequalities in hospital birth have almost disappeared despite persisting high user charges.15, 18 Women in only the least developed rural region (type 4) are lagging behind.18

Although data for China suggest that the hospital-based birth strategy has greatly reduced maternal mortality,17, 19 the role of institutional deliveries in neonatal mortality is unknown. We examined trends in neonatal mortality by cause in China from 1996 to 2008. We compared outcomes of home birth with those of hospital birth and incorporated China's socioeconomic regions into the analysis to indicate how the institutional intrapartum care strategy has affected neonatal mortality and its regional inequalities.

Section snippets

Data sources

We used data from China's National Maternal and Child Mortality Surveillance System (MCMS) between 1996 and 2008.17, 21 The MCMS was established in 1996 with a sample of 116 units (37 urban districts and 79 rural counties) representing 9% of all livebirths at the time. All districts and counties in China were stratified into six socioeconomic regions on the basis of social and economic indicators, which were the employment rate, the proportion of the population younger than 14 years and older

Results

The MCMS recorded 1 490 710 livebirths and 16 772 neonatal deaths from 1996 to 2008. Birth asphyxia (29·7%) and preterm birth complications (27·5%) were the most common causes of death, then congenital abnormalities (16·3%) and sepsis (11·7%; table 1). More than half of all neonatal deaths were within 2 days of birth, and 82% within the first week. Time of death varied by cause of death (p<0·0001). 81·8% of deaths from birth asphyxia were within 2 days of birth, whereas 88·1% of deaths from

Discussion

Our analysis of almost 1·5 million births in China shows that neonatal mortality decreased by 62% between 1996 and 2008. Although this finding represents substantial progress, regional disparities persist. The mortality rate in urban areas is approaching that in developed countries, but less developed rural areas are still lagging behind with annual rates of more than 20 per 1000 livebirths. Births in hospital are much safer than births at home, but institutional neonatal mortality rates in the

References (31)

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