Improving maternal healthcare further in China at a time of low maternal mortality

Characteristics of pregnant women

Changes in the characteristics of the pregnant population and the spectrum of obstetric diseases have emerged in China with population ageing and the relaxation of restrictions on the number of children a woman can have. These changes include older maternal age, a consistently high rate of caesarean section, increasing proportion of pregnancies with previous caesarean section, and coexisting threats from increasing maternal complications and chronic conditions.8

Low compliance with clinical guidelines among health professionals

Health professionals have insufficient knowledge and skills and low compliance with clinical guidelines in relation to maternal health. Prolonged use of antibiotics cannot improve the preventive effect further and may lead to increased bacterial resistance. In 2021, only 45.4% of prophylactic antibiotics were stopped within 24 hours of having a caesarean section as guidelines recommended.9 Postpartum haemorrhage is the leading cause of maternal death in China. A case review of 556 maternal deaths caused by obstetric haemorrhage in 2011-18 found that 71.8% of the factors attributable to healthcare were related to insufficient knowledge of haemorrhage risk or inadequate skills to respond to it among healthcare professionals at the rural or county level.1

Coexistence of insufficient healthcare and excessive medical interventions

In some rural areas and less developed provinces, it is still difficult to access specific antenatal care services and even sufficient contacts.2 At the same time, a trend of over-medicalisation in antenatal care has emerged in developed urban areas, which is characterised by too many antenatal care visits, cumbersome procedures, and an increasing number of non-essential examination items. For example, in the Tongzhou district of Beijing in 2017, more than 50% of pregnant women had more than 11 antenatal care visits.10 In addition, despite the implementation of universal two and three child policies, which can lead to pregnant women being more likely to choose vaginal delivery when giving birth to their first child, the overall annual rate of caesarean section in China did not decline as expected but increased from 43.4% in 2017 to 45.0% in 2022.8 The rate of caesarean section among nulliparous mothers substantially increased from 37.7% in 2018 to 43.6% in 2022, raising concerns about the risk of placental accreta, uterine rupture, and postpartum haemorrhage during their second pregnancy.8

Regional and institutional differences in quality of care

The disadvantages of lower availability of licensed maternal health facilities, obstetricians and midwives, and access to the recommended antenatal care visits in western China, which had poorer economic development compared with eastern China, have significantly improved.2 However, significant regional inequalities remain in the proportion of highly educated health professionals, quality of care, and outcomes of care—for example, maternal mortality ratio was 25.2 per 100 000 live births in western China versus 10.9 per 100 000 live births in eastern China in 2018.58 Notably, one third of all pregnant women gives birth in secondary level hospitals, which have relatively inadequate obstetric service capacity. For instance, the rate of neonatal asphyxia in secondary level hospitals is almost twice that in tertiary level hospitals.8

Career development for obstetric professionals

Obstetricians and midwives are more likely to work under greater pressure than other medical professionals because of concerns for maternal and fetal health. Moreover, the current payment mechanism of medical services and performance evaluation of public hospitals give more weight to disease treatment and surgical services, and to some extent neglect the efforts for disease prevention and health promotion integral to maternal healthcare. Salaries for obstetric health professionals are disproportionately low given the value and risk associated with these services, and hospitals providing more obstetric services will get lower performance scores. These factors, together with the declining fertility rate,11 have made obstetrics a marginalised service in hospital development and this has consequently become a growing concern for the career progression of obstetricians and midwives.

People centred regional network of maternal care

Given increasingly complex characteristics of pregnant women and indirect obstetric events becoming the main cause of maternal mortality, referral and cooperation among medical institutions is increasingly necessary for the successful management of high risk pregnant women. The cooperative network of maternal care connects all maternity and other health facilities through a management model which promotes a structure and culture that prioritises people centred, effective and efficient cooperation and collaborative learning.12 Studies show that such networks of maternal care have the potential to improve healthcare efficiency, continuity, quality and outcomes in resource limited settings.13

Both the United States and China have carried out trials on service delivery redesign aimed at establishing comprehensive networks for maternal care. In 2015, the American College of Obstetricians and Gynecologists, in collaboration with the Society for Maternal-Fetal Medicine, introduced a classification system categorising levels of maternal care. This system encompasses birth centres, basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal healthcare centres (level IV), each of which is designed to provide risk appropriate care.14

China started the Five Strategies for Maternal and Newborn Safety in 2017 as an integral part of its ambitious national public health programme within the framework of Healthy China 2030.15 The core constituents of these five strategies include risk screening and assessment, risk graded management and referral, case specific management of high risk pregnancies, strict reporting mechanisms, and a robust system of accountability.

To ensure the effective implementation of the five strategies, regional referral and treatment networks have been established, specifically designed to cater for critically ill pregnant women and newborns. These networks consist of maternal health facilities at various levels of care and multiple maternal and neonatal critical care centres. Within each county or district, prefecture, and province, these centres are managed by hospitals with strong comprehensive treatment capabilities. When necessary, patients can be seamlessly transferred from county level centres to municipal or provincial centres.

The success of this network relies on important elements including accurate risk assessment, sufficient information exchange, streamlined referral mechanisms, reasonable redesign of patient management responsibility, multidisciplinary teams, and collaborative learning. These mechanisms are crucial to ensure timely access to healthcare that meets the needs of pregnant women. Achievements have been made by this service delivery model in China, but some challenges remain in maintaining resilience of the network.

In the Chinese context, the risk based management of pregnant women mainly relies on the nominal level of a hospital rather than its actual treatment capacity.15 This may lead many pregnant women characterised as high risk to seek care in or be referred to tertiary hospitals, thereby increasing the burden on tertiary hospitals and reducing the capacity of primary maternal health facilities, which have already experienced a decrease in service demand owing to declining birth rates. This inefficient use of medical resources will adversely affect the overall effectiveness and efficiency of the healthcare system.

It is important to emphasise that referring high risk pregnant women to high level institutions is not the only solution to bridging the gap between healthcare demand and service delivery. Various factors, such as transportation, availability of medical resources, and coping strategies for patients who are reluctant to be referred, need to be considered when constructing a maternal care network. In certain situations, primary maternal health facilities may be the only option for high risk pregnant women to give birth. Therefore, the main goal should be to enhance the capacity of primary health facilities through collaboration between hospitals in the maternal care network. Higher level referral institutions in China are responsible for providing guidance and training for lower level hospitals. However, implementation of this support system needs improvement.

In countries in stage IV of obstetric transition, where chronic diseases are increasing, it is imperative that communities and primary healthcare are part of the maternal care network to ensure the consistency of care.16 Telemedicine and digital health advances (eg, support systems for clinical decision making enabled by artificial intelligence) can be used to improve the technical competency of primary healthcare professionals and increase their adherence to clinical guidelines, thereby improving clinical outcomes.17 Regional health information integration also contributes to the optimisation of the allocation of medical resources and the improvement of health service efficiency, as done in Yinzhou District of Ningbo City, China.18

Reducing regional inequalities in maternal health

China has taken action to eliminate regional inequalities in maternal health. The country has established 18 000 medical alliance­s—that is, integrated organisations formed within regions by medical institutions of different levels where members collaborate and share resources. Furthermore, 125 national regional medical centres have been established by top ranking hospitals independently or jointly establishing new branches across different regions. During the 14th Five Year Plan, 1953 tertiary hospitals provided targeted assistance to 1497 county level hospitals in 940 counties, fostering long term stable support and collaborative relationships. Other approaches taken to enhance equity include allowing top ranked hospitals to manage or merge with lower level hospitals and applying telemedicine technology.

Facilitating the transfer of medical resources from developed to developing areas is challenging. Government commitment to promoting this cross regional flow is essential. The sustainability and scalability of China’s measures remain to be tested. However, the effects of promoting medical equity have been observed. For example, in Xizang, pregnant women can access services at a new branch of the West China Women’s and Children’s Hospital of Sichuan University, which is one of western China’s top maternity hospitals.

Building a learning quality management system

In 2016, China introduced the Measures for the Management of Medical Quality, marking a milestone in medical quality control in the country. Since then, China has developed a hierarchical quality management framework that includes the NCHQMO, along with 31 provincial centres and increasing numbers of prefecture and county level centres, which are tasked with monitoring and improving the quality of healthcare. Several national big data platforms have been established to monitor the quality of healthcare services, including individual level data from the hospital quality monitoring system and hospital level data from the national clinical improvement system and NCHQMO. Nevertheless, several elements are needed to further advance quality improvement.

First, a comprehensive quality monitoring and assessment framework is needed—if you can’t measure it, you can’t improve it. In countries such as the United States and France, quality control indicators are mainly based on process oriented metrics.19 China introduced obstetric quality control indicators in 2019, most of which are outcome indicators owing to challenges in collecting process oriented data. To overcome this problem, we suggest that information systems be adapted to monitor maternal health and clinical practices by developing structured and standardised electronic medical records. Then, a comprehensive quality monitoring framework should be built that includes structure, process, and outcome indicators. In addition, it is important to develop methods to evaluate healthcare quality using these indicators at institutional and regional levels, which would not only assess the current healthcare landscape but also guide efforts to areas requiring improvement.

Second, a learning quality management system should be established. Measurement will not improve healthcare on its own and must be coupled with specific quality improvement actions, especially to tackle the aforementioned challenges. A quality management system with a learning culture has the capacity to adapt and reorganise quickly to deliver quality care. It is important to develop evidence based management strategies for critical pregnancy related or concurrent diseases, such as postpartum haemorrhage, hypertensive disorders, and pregnancy with cardiovascular disease.20 Treatment of these diseases may require multidisciplinary teams. In Sri Lanka, successful management strategies have been implemented to reduce maternal deaths from indirect causes associated with heart disease complicating pregnancy.21 In China, maternal mortality reviews have been carried out in almost all provinces, but studies on these death reviews are scarce, indicating that this mechanism has not been fully used for learning.22 Similarly, various large trials on service delivery redesign are under way in China and efforts have focused on taking action rather than looking back. More research on quality improvement and a comprehensive evaluation of the cost effectiveness and shortcomings of quality improvement models are needed.

Third, an equality improvement strategy is warranted. An equity lens should be applied to all quality improvement initiatives to tackle any inequalities.23 Achieving equity requires political and technological investment to develop information systems geared towards monitoring equity related concerns and establish a data driven framework for eliminating healthcare discrepancies by conducting thorough research in a wide range of areas related to fairness of maternal healthcare services.24 We call for involvement of pregnant women and healthcare professionals from different backgrounds in the process of developing, implementing, and evaluating quality improvement measures. Moreover, we recommend offering incentives for health professionals in primary hospitals to maintain and improve the continuity and quality of routine obstetric services. Broader reforms, including performance appraisal and service price control, are needed to relax restrictions in obstetric services and instil greater enthusiasm among obstetric healthcare workers to provide high quality services.