BMJ No 7098 Volume 314
Education and debate Saturday 7 June 1997
Health in China
Maternal and child health in China
Therese Hesketh, Wei Xing ZhuThis is the fourth in a series of five articles on changing aspects of health care in China
Summary
China has made great progress in improving the health of women and children over the past two generations. The success has been attributed to improved living standards, public health measures, and good access to health services. Although overall infant and maternal mortality rates are relatively low there are large differences in patterns of mortality between urban and rural areas. The Chinese have developed a hierarchical network of maternal and child health services, with each level taking a supervisory and teaching role for the level below it. Maternal and child health in China came to international attention in 1995 with the promulgation of the maternal and child health law. In China this was seen as a means of prioritising resources and improving the quality of services, but in the West it was widely described as a law on eugenics.The progress
Perhaps no other country in the world has achieved so much, so quickly, for the health of women and children. Just two generations ago Chinese women had bound feet and were the chattels of their menfolk. Now many women hold positions of considerable influence, with a level of equal opportunity and a sharing of domestic responsibilities that would be envied in many countries.
| Since Liberation in 1949, appreciable reductions in mortality and morbidity have been achieved with limited resources - through a host of measures including control of infectious diseases, improved sanitation, better availability of food, expansion of maternal and child health services, safer delivery practices, an increase in women's literacy, and access to family planning. Maternal mortality fell from over 1500/100,000 in 1950 to 50/100,000 in 1995 and the infant mortality rate fell from 250/1,000 to 37/1,000 (fig 1),(2) though when this rate is translated into actual numbers of deaths, China is still second only to India in total numbers of infant deaths per year. |  |  |
| Fig 1: Trends in infant mortality. Figures for 1992 and 1995 are official estimates |
This official infant mortality rate is widely acknowledged to be at least 20% lower than the actual figure. Underreporting of infant deaths occurs not only because of poor data collection in many areas but also because of the imperative for local officials to perform well and meet targets. This is encouraged by the bonuses and prestige accorded to "model" hospitals and counties that appear to perform well. In some counties year on year reductions in infant mortality since the early 1980s have been found to be fabricated. In fact, they have plateaued in most parts of China since then.
The urban-rural divide
| The overall mortality rates conceal wide variations between urban and poor rural areas. Maternal mortality differs at least fivefold, ranging from 18/100,000 in Shanghai to 108/100,000 in Ningxia.(3) In rural areas the most important cause of death is postpartum haemorrhage; in urban areas it is eclampsia.(4) Infant mortality rates show at least 10-fold differences: in Beijing the official rate is 10/1,000, with a pattern similar to developed countries. Neonatal causes, mostly prematurity, asphyxia, and infection, account for around two thirds of the deaths. In the poorest areas, where around 15% of the population lives, the rates are over 100/1,000 and the pattern is like that in the poorer developing countries, with postneonatal causes such as pneumonia and diarrhoea predominating.(1) | |
 |
| Paediatric ward at a county hospital in Jiangsu province |
There are differences also in nutritional status between the cities and the countryside: in poor rural areas undernutrition remains a problem, with 10-20% of children aged 1-4 years in rural areas below 80% of the median weight for age,(1) while in the cities childhood obesity is now starting to become a problem. However, nutritional deficiencies such as iron deficiency anaemia are not confined to the rural areas. Studies carried out in the late `80s estimated that 40% of all Chinese 7 year olds had haemoglobin concentrations below 11 g/l. In some rural areas over 80% of children were anaemic. Around 20% of 7 year olds overall have rickets, and rates in the rural north are as high as 50%.(5)
The maternal and child health hierarchy
The maternal and child health department at the ministry of public
health provides overall direction for maternal and child health
services. Ministerial directives are translated by the provincial
departments into implementation plans at city, county, township, and
village levels (right). At city and county level there is a maternal and
child health department at the bureau of public health which oversees
the activities of the hospitals and health centres providing maternal
and child health services.
The quality of services at each level varies enormously, depending on
location and resources available. Country doctors (previously barefoot
doctors) with three to six months' months training usually have
clinics in their own homes. Their equipment is basic, usually
consisting of the Three Instruments: stethoscope, sphygmomanometer, and
thermometer. Village maternal and child health workers provide some
basic antenatal, postpartum, and neonatal care as well as planning and,
in remote areas, delivery services.
Township health centres are usually staffed by doctors with two to three years' training and by midwives. The centres have an average of 15 inpatient beds across all specialties,(6) and in the larger health centres some operative procedures such as caesarean section can be carried out.
Most obstetricians, gynaecologists, and paediatricians work at county and city level. At county level there is a county hospital, like a district general hospital, with around 300 beds, and a maternal and child health centre. The centre is the cornerstone of the maternal and child health network and was introduced by the Russians in the 1950s. Here the medical staff provide antenatal and postnatal care and surveillance of infants and schoolchildren. Medical staff are also responsible for the training and supervision of lower level workers. One third of the clinical staff is required to spend one third of their time at the lower levels. There has been a programme of expansion and improvement of the maternal and child health centres over the past decade, with grants and loans easy to obtain. Now many centres are introducing more lucrative delivery services; in the new market system this puts them in direct competition with county hospitals. The county hospitals in many places are being forced to upgrade their facilities or face closure of their obstetric units.
In most cities several hospitals, usually including a specialised women's and children's hospital, provide maternal and child health services. High technology care is widely available, at a price, and many hospitals now have a neonatal and paediatric intensive care unit.
| There are clear advantages to such a hierarchical network: it
creates a referral network for high risk patients, and the supervision
system facilitates training and contact between health facilities,
which is much needed in remote areas. It also means that directives can
be acted on with sometimes astonishing speed. A good example of this is
the way that the "baby friendly initiative" was embraced. From
almost universal separation of babies and mothers after birth (at
county and city hospitals), rooming in was introduced across the
country in 1993. Three thousand hospitals were given the title Baby
Friendly Hospital in the first year. Breast feeding rates (at 1 week),
which had fallen to about 20% in cites like Hangzhou, now stand at
around 70%. But the vertical structure also leads to plurality of services and inefficiency. Family planning and immunisation programmes are run as entirely separate vertical programmes with their own provider units. In smaller counties there simply are not enough patients to justify a separate maternal and child health hospital. The duplication of staff and facilities, together with the underutilisation, makes the system inefficient. Nor is this good for patients: a woman may go to one hospital for her premarital examination, the maternal and child health centre for antenatal and postnatal care, and another hospital for delivery; her baby will be immunised at the anti-epidemic station, and she will go to the family planning clinic for contraception. |
|  |
| Where there is no rooming in, trolleys are used to bring babies to their mothers for breast feeding |
The maternal and child health law
The Chinese approach to maternal and child health came to international attention in 1995 with the enactment of the law on infant and maternal health (box). In Chinese maternal and child health circles the law is seen as a major step forward in attempts to improve health care for women and children. In the Western press it has been presented as a eugenics law and has been the subject of considerable debate.(7, 8) The word eugenics is in fact readily used in Chinese official circles. However, eugenics translates into Chinese as you sheng you yue, meaning "better birth, better care," and does not have the negative overtones that the word has in the West.
| Law on Infant and Maternal Health (enacted 1 June 1995) | |||||||||||||||||||||||||||||||||
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There can be no doubt that most of the 38 articles of the law are positive. For example, during pregnancy women must receive instruction on healthy pregnancy, "rearing of the next generation" and "endemic diseases such as iodine deficiency syndrome." The law states that "pregnant and post-partum women should receive advice on hygiene, nutrition, and psychology." In addition, fetal sex determination is strictly illegal (except on medical grounds), with stiff penalties for any professionals and institutions involved. Some of the areas that seem controversial to Westerners merely state what has been accepted practice in China for many years - for example, the examination before marriage, with postponement of marriage if serious disease is found, to allow for investigation and treatment.
Two articles contain overtly eugenic elements: article 10 states that "if a couple both have a genetic defect which would make childbearing inappropriate from a medical point of view, then the marriage can only take place if the couple agree to take long term contraceptive measures or be sterilised." Article 18 states that "medical advice for a termination of pregnancy must be given if the fetus has a genetic disease of a serious matter or a serious defect or if the mother's life is threatened."
Western commentators have raised serious concerns about the lack of clear definition of the conditions for which termination would be advised.(9) But the Chinese deny that this is a law on eugenics (by Western definitions). They make several points: firstly, the anomalies covered under the law are rare. Antenatal diagnosis is still crude, so the issue of terminations for minor abnormalities doesn't arise. Secondly, there is no way of forcing a couple to take contraceptive measures if they refuse. Thirdly, termination can only be advised and force is totally unacceptable. Finally, in China it is very unusual for a couple to choose to have a child if they know it will be abnormal.
This final point is crucial. The maternal and child health law does not force people into eugenic abortions - it makes abortions more readily available to those who want them.(9) The decision has a clear economic rationale. A disabled child will probably not be able to support aging parents and will be a considerable financial drain because of the high costs of education and health care.
The main challenges for China's maternal and child health services are twofold: to protect the gains already made for the majority, while maintaining the momentum for improvement, and to prioritise resources to the poorest areas. The maternal and child health law will go some way at least to help the poorest areas.
Centre for International Child Health,
London
WC1 N1EH
Therese Hesketh,
research fellow
Health Unlimited,
London SE1 9NT
Wei Xing
Zhu,
programme manager, East
Asia
Correspondence to: Dr Hesketh.
References
1 Unicef. Children and women of China: a Unicef situation analysis. Beijing: Unicef, 1989.
2 Chinese Health Statistics Digest. Beijing: Ministry of Public Health, 1995.
3 Young M E. Maternal health in China: challenges of the next decade. Health Policy 1990;14:87-125.
4 Zhang L M, Ding H. Analysis of the causes of maternal death in China. Bull WHO 1988;66:387-90.
5 Zheng Y. Three Bests programme to help children. China Daily 1996 November 23.
6 Liu X Z, Wang J L. An introduction to China's healthcare system. J Public Health Policy 1991;12:104-16.
7 Western eyes on China's eugenics law [editorial]. Lancet 1995;34:131.
8 Hawkes N. Scientists attack China over selective breeding. The Times 1995 June 5.
9 Anton M. MCH law: a eugenics law. China Review 1996;4:29.
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