我国孕产妇与儿童卫生干预措施覆盖率的现状及公平性研究
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摘要
一、研究背景
近二十年来,我国孕产妇和儿童的生存状况有了明显的改善,己基本达到了联合国制定的千年发展目标4和5。然而孕产妇与儿童的生存与健康仍面临着两个巨大的挑战。一是既往我国的妇幼卫生体系中缺乏整合和连续性,使妇幼卫生服务的成本——效益没有得到最大化。二是孕产妇和儿童生存整体的改善掩盖了地区和人群间的差异。既往研究已经明确整合若干孕产妇和儿童卫生干预措施可以有效降低孕产妇和儿童死亡。而要连续、有效地改善孕产妇和儿童生存与健康,弥合不同地区和人群之间的差异,就需要综合反映保健连续性的孕产妇和儿童卫生干预措施覆盖率指标,并对干预措施覆盖率在不同地区和不同人群的差异进行分析,既有利于卫生服务资源的合理导向与配置,又可以明确需要重点干预的人群并制定相应的干预策略。
近年来国内外对于妇幼卫生健康公平性的研究热度递增。在发展中国家的研究中发现社会经济状况好的家庭孕产妇和儿童卫生干预措施覆盖率普遍优于社会经济状况差的家庭,城市地区、受教育程度高、和非少数民族的妇幼卫生服务利用程度更好。我国的研究也有类似的发现,在农村地区、贫困家庭孕产妇保健的利用程度较差。
然而现有的文献中均在以下几点局限性：1)尚没有体现保健连续性的孕产妇和儿童干预措施指标体系。2)孕产妇产前保健和产后保健的公平性研究结论不一致,有待于进一步验证和分析。且尚未发现针对儿童卫生服务(如免疫接种、常见病管理)公平性的研究。3)个体水平卫生服务公平性的研究和对公平性影响因素进行探索的研究甚少。
因此本研究通过选择综合评价孕产妇和儿童卫生干预措施覆盖率的指标,并应用不公平的测度方法描述我国地区和个体(不同家庭社会经济状况)两个层面孕产妇和儿童卫生干预措施的现状和不公平程度,并探讨其影响因素。
二、研究方法
本研究数据来源于2008年开展的第四次国家卫生服务调查的家庭健康询问调查部分,共计调查了全国31个省、自治区、直辖市共56456户家庭。由经过培训的卫生工作者使用结构式问卷进行询问。本研究中仅采用家庭健康询问调查部分的家庭一般情况、家庭成员健康询问调查、15-49岁已婚育龄妇女情况和5岁以下儿童情况四个部分的数据。分析产前、产时和产后孕产妇干预措施以及早开奶时,分析的样本量为7414名母亲——儿童对。而在分析儿童喂养(除早开奶外)、免疫接种和儿童腹泻时,总分析的样本量为9639名5岁以下儿童。
通过回顾目前国际上通用的孕产妇和儿童卫生干预措施覆盖率指标体系和国内的指标体系,最终选择了11项孕产妇和儿童卫生干预措施覆盖率作为分析的核心指标。通过加权计算描述我国孕产妇和儿童卫生干预措施覆盖率的现状和地区差异、采用绝对差值和相对比值来定量分析地区差异的大小,并辅以地理分布图来直观呈现各省的分布。以家庭人均年生活消费性支出作为划分人群社会经济状况的依据,并采用健康不公平绝对和相对指标(集中指数)来测度孕产妇和儿童卫生干预措施的覆盖率的公平性,通过(Q1-Q2)/(Q5-Q4)和图示计算不公平的类型。
三、研究结果
(一)孕产妇与儿童卫生干预措施覆盖率的现状
至少进行一次产前保健和住院分娩的覆盖率最高,分别为94.65%和89.55%。儿童期辅食添加、免疫接种和腹泻的口服补液治疗的覆盖率分别为72.45%、80.38%和73.96%。至少进行1次产后访视的覆盖率为53.94%。产前保健的质量指标的两项指标(满足产前检查基本质量和产前保健至少5次且满足产前检查基本质量)的覆盖率为62.01%和39.08%。早开奶和纯母乳喂养6个月的比例均低于40%。
(二)孕产妇与儿童卫生干预措施覆盖率的地区差异
通过地区和分省分析,孕产妇和儿童卫生干预措施最低的仍然多集中在西部省份,如云南、青海、贵州、新疆、西藏等省份。尽管大多数孕产妇和儿童卫生干预措施在城乡之间未见显著的差别,然而Ⅳ类农村地区产前保健和住院分娩最低。此外,与至少进行过一次产前保健的高覆盖率(95%)相比,至少进行过4次或5次产前保健以及满足产前检查基本质量的比例则仅为66%、52%和62%,而产前保健至少5次且满足产前保健基本质量的比例更低(39.08%)。
(三)孕产妇与儿童卫生干预措施覆盖率的公平性
无论其整体覆盖率的高低,产前、产时和产后保健的集中指数均大于0,提示存在着随家庭社会经济状况升高而覆盖率增加的趋势,即亲富人(pro-rich)现象,且不同指标之间的不公平程度也存在差异。最富裕与最贫困人群产前保健至少5次且满足产前检查基本质量覆盖率的绝对差值达到了57%,最富裕人群的覆盖率是最贫困人群的3.94倍。住院分娩在最贫困与最富裕人群覆盖率的差距较小(差值为12%,比值为1.15)。产后访视整体的覆盖率低,而最富裕与最贫困人群之间的覆盖率也存在着差距(差值为25%,比值为1.58)。婴幼儿喂养中仅发现纯母乳喂养6个月存在不公平的现象(集中指数=-0.93,P<0.0001),其覆盖率随着家庭社会经济状况的上升而下降,即“亲穷人”。对于免疫接种和儿童腹泻的管理,本研究没有发现显著的不公平现象。
对于不公平类型的分析发现,整体覆盖率高(≥90%)的干预措施(如至少进行一次产前保健、住院分娩),其不公平的类型为bottom型,提示家庭社会经济状况最差的20%的人群干预措施的覆盖率明显落后于其他等级。而覆盖率低(39%-70%)的干预措施(如至少进行过5次产前保健、孕早期进行产前保健、有质量的产前保健、至少进行过4次产前保健且有质量的产前保健以及至少进行过5次产前保健且有质量的产前保健),其不公平的类型为top型,即家庭社会经济状况最好的20%的人群干预措施的覆盖率明显优于其他等级。
(四)不公平的影响因素
家庭人均年生活消费性支出在产前保健和产后保健不公平中所占比重最大(47.05%-118.8%)。反映产前保健质量的有效覆盖率指标中,母亲职业和东中西部地区对不公平的贡献率则分别为0.1845-0.2029和0.1212-0.1264。至少进行一次产后保健“亲富人”贡献大的影响因素也包括东中西部地区(贡献率为0.1540)和母亲职业(贡献率为0.1474)。住院分娩不公平的影响因素分别是母亲教育程度(贡献率为0.3690)、家庭人均年生活消费性支出(贡献率为0.2401)和母亲产次(贡献率为0.1768)。
四、结论
我国孕产妇和儿童卫生服务存在发展不平衡。产前、产时保健和儿童期的免疫接种均已达到了较高的覆盖率,然而产后保健、婴幼儿喂养的覆盖率则较低。孕产妇和儿童保健干预措施最低的仍然多集中在西部省份和Ⅳ类农村地区,提示西部和偏远落后的农村地区仍然是没有得到孕产妇和儿童卫生干预措施的有效覆盖,是未来妇幼卫生工作的重点。此外,尽管产前保健的粗干预措施覆盖率高,但是产前保健质量较差且地区差异大。可见即使医疗卫生服务达到了较高的利用,如不加强医疗卫生机构的服务质量、提高卫生工作者的技能和服务水平,孕产妇和儿童卫生干预措施仍未全面惠及目标人群,有效改善孕产妇和儿童的生存与健康。无论整体覆盖率的高低,产前、产时和产后保健均存在着随家庭社会经济状况升高而覆盖率增加的趋势,即亲富人(pro-rich)现象。但干预措施的不公平类型不尽相同。不公平类型的研究也有助于了解干预措施实施过程不公平产生的规律与趋势,从而采取不同的策略尽量弥合不公平。
家庭人均年生活消费性支出在产前和产后保健不公平中所占比重最大,说明影响产前和产后保健不公平的主要因素是家庭对于孕期和产后相关医疗卫生保健服务的购买力。反映产前保健质量的有效覆盖率指标中,母亲职业和东中西部地区对不公平的贡献,说明母亲职业和中西部地区对孕期相关医疗卫生服务利用的不公平也有一定的影响。消除健康不公平既可以采用重点人群的直接干预,也可以实施惠及全体居民的全面覆盖策略。无论何种策略的实施,都需要建立妇幼卫生公平性的监测和评估系统,对孕产妇和儿童卫生干预措施的公平性及影响因素进行持续的监测,明确重点人群并建立追踪机制,为促进卫生服务的公平利用提供理论依据和证据支持。
Background and objective
During the past two decades, the survival status of women and children in China has been greatly improved and the Millennium Development Goals four and five established by the United Nation have been achieved. The continuum of care was conceptualized from the World Health Report in2005and later be defined by Kerber KJ et al. And lack of integration among maternal and child health system in China has hampered the improvement of the survival and health among mothers and their children. To further improve the survival and health of women and children in China, we need to internalize the continuum of care and integrate the service delivery strategy for maternal and child health system. Moreover, the general improvement of maternal and child survival may conceal the disparity across regions or subgroup populations, which is becoming another major challenge in the area of maternal and child health. Studies have identified several maternal and child survival interventions that can effectively prevent mother and their children from dying. Therefore, to close the gap of child survival across various regions or subgroup population, we need to construct a series of indicators reflect the continuum of care and analyzing of difference of coverage across region and subpopulation.
Research on inequity of maternal and child health has been a hot area in recent years. In developing countries, pro-rich inequities are prevalent in maternal and child health interventions, which means inequity were found favoring urban families, mother with higher education and non-ethnical minorities. Similar findings also have reported in China. Rural residents and poor family were less covered by maternal and child health interventions.
However, several literature gaps have also been identified:1) We haven't identified any key indicators on maternal and child health interventions that represent the continuum of care.2) Different findings on inequities of antenatal and postnatal care have been reported and child health care interventions such as immunization and common childhood illnesses management have rarely been studies.3) Few inequities studies of maternal and child health at individual level have been reported. Only few studies reported the factors that contributed to the inequity found in maternal and child health interventions.
Therefore, the aim of our study is to select key maternal and child health intervention indicators and to use inequity assessment approaches to measure the general coverage, regional disparity and inequity.
Methods
The data used in the analysis was from the forth National Health Service Survey (NHSS) including56456households from31provinces, autonomous regions and municipalities. The family health status survey was part of the NHSS and structured questionnaires were administered by the trained township health workers in this survey. Our analysis only included the modules of general characteristics of households, health status of family members, married women at reproductive age (15-49years of age) and children under5years of age in the family health status survey. When assessing the coverage on antenatal, intrapartum and postpartum interventions and early initiation of breastfeeding, total7414mother-child pairs were included in the analysis pool. However, when analyzing infant and young child feeding (except for early initiation of breastfeeding), immunization and childhood diarrhea and management, the sample size was9639.
By reviewing international and domestic maternal and child health coverage indicators,11key coverage indicators were chosen as the core indicators. The weighted coverage of maternal and child health interventions across different regions were explored and quantified by absolute difference and ratio. The geographic mapping tool was also used to display the provincial disparities of coverage. The per capita annual consumptive expenditure was used to categorize population into five socio-economic levels, the absolute difference between the poorest20%and the richest20%, ratio of the poorest20%and the richest20%and concentration index (CI) were calculated to measure the extent of inequity. For those inequitable coverage, the pattern of inequity was also assessed by the ratio of (Q1-Q2) and (Q5-Q4) and figures. Furthermore, decomposing of CI was used to explore the factors that contributed to the inequity health interventions.
Results
Coverage of key maternal and child health interventions
The coverage for at least once antenatal care and hospital delivery were94.65%and89.55%, respectively. The quality of antenatal care was measured by two indicators. One is minimum acceptable quality (including weighing, measuring blood pressure, blood routine test and urine routine test) and the coverage was62.01%. Another is at least five times of antenatal care with minimum acceptable quality and the proportion was39.08%.53.94%women received postnatal care at least once. Around72.45%of children were introduced complementary feeding between six to nine months of age while continued breastfeeding and80.38%children between12to59months of age were fully immunized (one dose of BCG and measles, three doses of DPT, HBV and polio). For children whose caregivers reported to have diarrhea two weeks prior the survey date,73.96%of them received oral rehydration therapy. However, the coverage of early initiation of breastfeeding and exclusively breastfeeding for six months were all lower than40%.
Regional disparity of key maternal and child health interventions
Based on the regional and provincial analysis, the lowest coverage of key maternal and child health interventions were in western provinces such as Yunan, Guizhou, Xinjiang and Tibet. Although there were no significant differences between rural and urban areas in most of the maternal and child health key indicators, rural type IV area has the lowest coverage of antenatal care and hospital delivery. Moreover, compare to nearly universal coverage of at least once antenatal care visit (95%), at least four and five times of antenatal care visit and the minimum acceptable quality indicators were found to be low (66%,52%and62%). Only39.08%women received at least five times of antenatal care visits with minimum acceptable quality.
Inequity of key maternal and child health interventions
Prevalent pro-rich inequities were found among antenatal care, delivery and postnatal care interventions, indicating those interventions were favoring the population with better socio-economic status. The extent of inequity also varied from intervention to intervention. The absolute difference and ratio between the richest20%population and the poorest20%population for at least five times of antenatal care visit and the minimum acceptable quality were57%and3.94. The coverage gap of hospital delivery between the richest20%population and the poorest20%population were smaller (difference was 25%and the ratio was1.58). On the contrary, exclusively breastfeeding for6months was pro-poor (CI=-0.93, P<0.0001) indicating children from low socio-economic families were exclusively breastfed more than their counterparts from better socio-economic families. We did not found inequity for immunization and childhood diarrhea management indicators.
After analyzing the inequity pattern, interventions with high coverage (≥90%) follow the bottom pattern of inequity while interventions with low coverage (39%-70%) present a top pattern.
Decomposing health inequity
In antenatal care and postnatal care, most of the consumption-related inequity was explained by the direct effect of per capita annual family consumption(percentage contribution=0.4705-1.188). Compare to crude coverage indicator of antenatal care, living in eastern/middle/western areas (percentage contribution=0.1845-0.2029) and maternal occupation (percentage contribution=0.1212-0.1264) are also seen to be the main driver of the inequity of effective coverage of antenatal care. Maternal education(percentage contribution=0.3690), per capita annual family consumption (percentage contribution=0.2401) and maternal parity (percentage contribution=0.1768) contributed to the pro-rich inequity of hospital delivery.
Conclusion
Maternal and child health interventions were imbalanced distributed from pregancy through delivery to childhood. Our study indicated that comparting to high coverage of antenatal care, intrapatum interventions and immunization, postnatal care and infant and young child feeding were lower. Western and rural type IV area had the lowest coverage for most of the maternal and child health interventions, suggesting further emphasized should placed on scaling-up the key maternal and child health interventions on western and remote rural areas. Although the proportion of as least once antenatal care was high, the quality of antenatal care was suboptimal with wide regional diasparity. Even the health care service utlization attained a high level, without improved quality in health care facilities and strengthened capaciliy and skill among health workers, the intervention would not benefit the population in need effectively. Pro-rich inequities were prevalent among antenatal, intrapartum and post partum cares. The inequity pattern also varied across different key maternal and child health interventions. To close the gap of inequities, tailored strategies should be implemented according to certain inequity patterns. Consumption-related inequity is mainly explained by the direct effect of per capita annual family consumption for antenatal care and postnatal care. The purchasing power of residents was seen to be the main barrier for utilization of services during pregnancy and after delivery. Living in eastern/middle/western areas and maternal occupation also explained part of the pro-rich inequity of effective coverage of antenatal care. To address to health inequity of maternal and child health interventions, targeting the disadvantage population or universal coverage can be applied. No matter what strategy is chosen, it is essential to build a maternal and child health inequity monitoring and evaluation system to continuously measure the inequity and its influential factors for maternal and child health interventions. Moreover, to identify and prospectively track of high risk population using the data from this maternal and child health inequity monitoring and evaluation system is also needed, which could facilitate evidence-based policy making on closing the gap of maternal and child health.
近二十年来,我国孕产妇和儿童的生存状况有了明显的改善,己基本达到了联合国制定的千年发展目标4和5。然而孕产妇与儿童的生存与健康仍面临着两个巨大的挑战。一是既往我国的妇幼卫生体系中缺乏整合和连续性,使妇幼卫生服务的成本——效益没有得到最大化。二是孕产妇和儿童生存整体的改善掩盖了地区和人群间的差异。既往研究已经明确整合若干孕产妇和儿童卫生干预措施可以有效降低孕产妇和儿童死亡。而要连续、有效地改善孕产妇和儿童生存与健康,弥合不同地区和人群之间的差异,就需要综合反映保健连续性的孕产妇和儿童卫生干预措施覆盖率指标,并对干预措施覆盖率在不同地区和不同人群的差异进行分析,既有利于卫生服务资源的合理导向与配置,又可以明确需要重点干预的人群并制定相应的干预策略。
近年来国内外对于妇幼卫生健康公平性的研究热度递增。在发展中国家的研究中发现社会经济状况好的家庭孕产妇和儿童卫生干预措施覆盖率普遍优于社会经济状况差的家庭,城市地区、受教育程度高、和非少数民族的妇幼卫生服务利用程度更好。我国的研究也有类似的发现,在农村地区、贫困家庭孕产妇保健的利用程度较差。
然而现有的文献中均在以下几点局限性：1)尚没有体现保健连续性的孕产妇和儿童干预措施指标体系。2)孕产妇产前保健和产后保健的公平性研究结论不一致,有待于进一步验证和分析。且尚未发现针对儿童卫生服务(如免疫接种、常见病管理)公平性的研究。3)个体水平卫生服务公平性的研究和对公平性影响因素进行探索的研究甚少。
因此本研究通过选择综合评价孕产妇和儿童卫生干预措施覆盖率的指标,并应用不公平的测度方法描述我国地区和个体(不同家庭社会经济状况)两个层面孕产妇和儿童卫生干预措施的现状和不公平程度,并探讨其影响因素。
二、研究方法
本研究数据来源于2008年开展的第四次国家卫生服务调查的家庭健康询问调查部分,共计调查了全国31个省、自治区、直辖市共56456户家庭。由经过培训的卫生工作者使用结构式问卷进行询问。本研究中仅采用家庭健康询问调查部分的家庭一般情况、家庭成员健康询问调查、15-49岁已婚育龄妇女情况和5岁以下儿童情况四个部分的数据。分析产前、产时和产后孕产妇干预措施以及早开奶时,分析的样本量为7414名母亲——儿童对。而在分析儿童喂养(除早开奶外)、免疫接种和儿童腹泻时,总分析的样本量为9639名5岁以下儿童。
通过回顾目前国际上通用的孕产妇和儿童卫生干预措施覆盖率指标体系和国内的指标体系,最终选择了11项孕产妇和儿童卫生干预措施覆盖率作为分析的核心指标。通过加权计算描述我国孕产妇和儿童卫生干预措施覆盖率的现状和地区差异、采用绝对差值和相对比值来定量分析地区差异的大小,并辅以地理分布图来直观呈现各省的分布。以家庭人均年生活消费性支出作为划分人群社会经济状况的依据,并采用健康不公平绝对和相对指标(集中指数)来测度孕产妇和儿童卫生干预措施的覆盖率的公平性,通过(Q1-Q2)/(Q5-Q4)和图示计算不公平的类型。
三、研究结果
(一)孕产妇与儿童卫生干预措施覆盖率的现状
至少进行一次产前保健和住院分娩的覆盖率最高,分别为94.65%和89.55%。儿童期辅食添加、免疫接种和腹泻的口服补液治疗的覆盖率分别为72.45%、80.38%和73.96%。至少进行1次产后访视的覆盖率为53.94%。产前保健的质量指标的两项指标(满足产前检查基本质量和产前保健至少5次且满足产前检查基本质量)的覆盖率为62.01%和39.08%。早开奶和纯母乳喂养6个月的比例均低于40%。
(二)孕产妇与儿童卫生干预措施覆盖率的地区差异
通过地区和分省分析,孕产妇和儿童卫生干预措施最低的仍然多集中在西部省份,如云南、青海、贵州、新疆、西藏等省份。尽管大多数孕产妇和儿童卫生干预措施在城乡之间未见显著的差别,然而Ⅳ类农村地区产前保健和住院分娩最低。此外,与至少进行过一次产前保健的高覆盖率(95%)相比,至少进行过4次或5次产前保健以及满足产前检查基本质量的比例则仅为66%、52%和62%,而产前保健至少5次且满足产前保健基本质量的比例更低(39.08%)。
(三)孕产妇与儿童卫生干预措施覆盖率的公平性
无论其整体覆盖率的高低,产前、产时和产后保健的集中指数均大于0,提示存在着随家庭社会经济状况升高而覆盖率增加的趋势,即亲富人(pro-rich)现象,且不同指标之间的不公平程度也存在差异。最富裕与最贫困人群产前保健至少5次且满足产前检查基本质量覆盖率的绝对差值达到了57%,最富裕人群的覆盖率是最贫困人群的3.94倍。住院分娩在最贫困与最富裕人群覆盖率的差距较小(差值为12%,比值为1.15)。产后访视整体的覆盖率低,而最富裕与最贫困人群之间的覆盖率也存在着差距(差值为25%,比值为1.58)。婴幼儿喂养中仅发现纯母乳喂养6个月存在不公平的现象(集中指数=-0.93,P<0.0001),其覆盖率随着家庭社会经济状况的上升而下降,即“亲穷人”。对于免疫接种和儿童腹泻的管理,本研究没有发现显著的不公平现象。
对于不公平类型的分析发现,整体覆盖率高(≥90%)的干预措施(如至少进行一次产前保健、住院分娩),其不公平的类型为bottom型,提示家庭社会经济状况最差的20%的人群干预措施的覆盖率明显落后于其他等级。而覆盖率低(39%-70%)的干预措施(如至少进行过5次产前保健、孕早期进行产前保健、有质量的产前保健、至少进行过4次产前保健且有质量的产前保健以及至少进行过5次产前保健且有质量的产前保健),其不公平的类型为top型,即家庭社会经济状况最好的20%的人群干预措施的覆盖率明显优于其他等级。
(四)不公平的影响因素
家庭人均年生活消费性支出在产前保健和产后保健不公平中所占比重最大(47.05%-118.8%)。反映产前保健质量的有效覆盖率指标中,母亲职业和东中西部地区对不公平的贡献率则分别为0.1845-0.2029和0.1212-0.1264。至少进行一次产后保健“亲富人”贡献大的影响因素也包括东中西部地区(贡献率为0.1540)和母亲职业(贡献率为0.1474)。住院分娩不公平的影响因素分别是母亲教育程度(贡献率为0.3690)、家庭人均年生活消费性支出(贡献率为0.2401)和母亲产次(贡献率为0.1768)。
四、结论
我国孕产妇和儿童卫生服务存在发展不平衡。产前、产时保健和儿童期的免疫接种均已达到了较高的覆盖率,然而产后保健、婴幼儿喂养的覆盖率则较低。孕产妇和儿童保健干预措施最低的仍然多集中在西部省份和Ⅳ类农村地区,提示西部和偏远落后的农村地区仍然是没有得到孕产妇和儿童卫生干预措施的有效覆盖,是未来妇幼卫生工作的重点。此外,尽管产前保健的粗干预措施覆盖率高,但是产前保健质量较差且地区差异大。可见即使医疗卫生服务达到了较高的利用,如不加强医疗卫生机构的服务质量、提高卫生工作者的技能和服务水平,孕产妇和儿童卫生干预措施仍未全面惠及目标人群,有效改善孕产妇和儿童的生存与健康。无论整体覆盖率的高低,产前、产时和产后保健均存在着随家庭社会经济状况升高而覆盖率增加的趋势,即亲富人(pro-rich)现象。但干预措施的不公平类型不尽相同。不公平类型的研究也有助于了解干预措施实施过程不公平产生的规律与趋势,从而采取不同的策略尽量弥合不公平。
家庭人均年生活消费性支出在产前和产后保健不公平中所占比重最大,说明影响产前和产后保健不公平的主要因素是家庭对于孕期和产后相关医疗卫生保健服务的购买力。反映产前保健质量的有效覆盖率指标中,母亲职业和东中西部地区对不公平的贡献,说明母亲职业和中西部地区对孕期相关医疗卫生服务利用的不公平也有一定的影响。消除健康不公平既可以采用重点人群的直接干预,也可以实施惠及全体居民的全面覆盖策略。无论何种策略的实施,都需要建立妇幼卫生公平性的监测和评估系统,对孕产妇和儿童卫生干预措施的公平性及影响因素进行持续的监测,明确重点人群并建立追踪机制,为促进卫生服务的公平利用提供理论依据和证据支持。
Background and objective
During the past two decades, the survival status of women and children in China has been greatly improved and the Millennium Development Goals four and five established by the United Nation have been achieved. The continuum of care was conceptualized from the World Health Report in2005and later be defined by Kerber KJ et al. And lack of integration among maternal and child health system in China has hampered the improvement of the survival and health among mothers and their children. To further improve the survival and health of women and children in China, we need to internalize the continuum of care and integrate the service delivery strategy for maternal and child health system. Moreover, the general improvement of maternal and child survival may conceal the disparity across regions or subgroup populations, which is becoming another major challenge in the area of maternal and child health. Studies have identified several maternal and child survival interventions that can effectively prevent mother and their children from dying. Therefore, to close the gap of child survival across various regions or subgroup population, we need to construct a series of indicators reflect the continuum of care and analyzing of difference of coverage across region and subpopulation.
Research on inequity of maternal and child health has been a hot area in recent years. In developing countries, pro-rich inequities are prevalent in maternal and child health interventions, which means inequity were found favoring urban families, mother with higher education and non-ethnical minorities. Similar findings also have reported in China. Rural residents and poor family were less covered by maternal and child health interventions.
However, several literature gaps have also been identified:1) We haven't identified any key indicators on maternal and child health interventions that represent the continuum of care.2) Different findings on inequities of antenatal and postnatal care have been reported and child health care interventions such as immunization and common childhood illnesses management have rarely been studies.3) Few inequities studies of maternal and child health at individual level have been reported. Only few studies reported the factors that contributed to the inequity found in maternal and child health interventions.
Therefore, the aim of our study is to select key maternal and child health intervention indicators and to use inequity assessment approaches to measure the general coverage, regional disparity and inequity.
Methods
The data used in the analysis was from the forth National Health Service Survey (NHSS) including56456households from31provinces, autonomous regions and municipalities. The family health status survey was part of the NHSS and structured questionnaires were administered by the trained township health workers in this survey. Our analysis only included the modules of general characteristics of households, health status of family members, married women at reproductive age (15-49years of age) and children under5years of age in the family health status survey. When assessing the coverage on antenatal, intrapartum and postpartum interventions and early initiation of breastfeeding, total7414mother-child pairs were included in the analysis pool. However, when analyzing infant and young child feeding (except for early initiation of breastfeeding), immunization and childhood diarrhea and management, the sample size was9639.
By reviewing international and domestic maternal and child health coverage indicators,11key coverage indicators were chosen as the core indicators. The weighted coverage of maternal and child health interventions across different regions were explored and quantified by absolute difference and ratio. The geographic mapping tool was also used to display the provincial disparities of coverage. The per capita annual consumptive expenditure was used to categorize population into five socio-economic levels, the absolute difference between the poorest20%and the richest20%, ratio of the poorest20%and the richest20%and concentration index (CI) were calculated to measure the extent of inequity. For those inequitable coverage, the pattern of inequity was also assessed by the ratio of (Q1-Q2) and (Q5-Q4) and figures. Furthermore, decomposing of CI was used to explore the factors that contributed to the inequity health interventions.
Results
Coverage of key maternal and child health interventions
The coverage for at least once antenatal care and hospital delivery were94.65%and89.55%, respectively. The quality of antenatal care was measured by two indicators. One is minimum acceptable quality (including weighing, measuring blood pressure, blood routine test and urine routine test) and the coverage was62.01%. Another is at least five times of antenatal care with minimum acceptable quality and the proportion was39.08%.53.94%women received postnatal care at least once. Around72.45%of children were introduced complementary feeding between six to nine months of age while continued breastfeeding and80.38%children between12to59months of age were fully immunized (one dose of BCG and measles, three doses of DPT, HBV and polio). For children whose caregivers reported to have diarrhea two weeks prior the survey date,73.96%of them received oral rehydration therapy. However, the coverage of early initiation of breastfeeding and exclusively breastfeeding for six months were all lower than40%.
Regional disparity of key maternal and child health interventions
Based on the regional and provincial analysis, the lowest coverage of key maternal and child health interventions were in western provinces such as Yunan, Guizhou, Xinjiang and Tibet. Although there were no significant differences between rural and urban areas in most of the maternal and child health key indicators, rural type IV area has the lowest coverage of antenatal care and hospital delivery. Moreover, compare to nearly universal coverage of at least once antenatal care visit (95%), at least four and five times of antenatal care visit and the minimum acceptable quality indicators were found to be low (66%,52%and62%). Only39.08%women received at least five times of antenatal care visits with minimum acceptable quality.
Inequity of key maternal and child health interventions
Prevalent pro-rich inequities were found among antenatal care, delivery and postnatal care interventions, indicating those interventions were favoring the population with better socio-economic status. The extent of inequity also varied from intervention to intervention. The absolute difference and ratio between the richest20%population and the poorest20%population for at least five times of antenatal care visit and the minimum acceptable quality were57%and3.94. The coverage gap of hospital delivery between the richest20%population and the poorest20%population were smaller (difference was 25%and the ratio was1.58). On the contrary, exclusively breastfeeding for6months was pro-poor (CI=-0.93, P<0.0001) indicating children from low socio-economic families were exclusively breastfed more than their counterparts from better socio-economic families. We did not found inequity for immunization and childhood diarrhea management indicators.
After analyzing the inequity pattern, interventions with high coverage (≥90%) follow the bottom pattern of inequity while interventions with low coverage (39%-70%) present a top pattern.
Decomposing health inequity
In antenatal care and postnatal care, most of the consumption-related inequity was explained by the direct effect of per capita annual family consumption(percentage contribution=0.4705-1.188). Compare to crude coverage indicator of antenatal care, living in eastern/middle/western areas (percentage contribution=0.1845-0.2029) and maternal occupation (percentage contribution=0.1212-0.1264) are also seen to be the main driver of the inequity of effective coverage of antenatal care. Maternal education(percentage contribution=0.3690), per capita annual family consumption (percentage contribution=0.2401) and maternal parity (percentage contribution=0.1768) contributed to the pro-rich inequity of hospital delivery.
Conclusion
Maternal and child health interventions were imbalanced distributed from pregancy through delivery to childhood. Our study indicated that comparting to high coverage of antenatal care, intrapatum interventions and immunization, postnatal care and infant and young child feeding were lower. Western and rural type IV area had the lowest coverage for most of the maternal and child health interventions, suggesting further emphasized should placed on scaling-up the key maternal and child health interventions on western and remote rural areas. Although the proportion of as least once antenatal care was high, the quality of antenatal care was suboptimal with wide regional diasparity. Even the health care service utlization attained a high level, without improved quality in health care facilities and strengthened capaciliy and skill among health workers, the intervention would not benefit the population in need effectively. Pro-rich inequities were prevalent among antenatal, intrapartum and post partum cares. The inequity pattern also varied across different key maternal and child health interventions. To close the gap of inequities, tailored strategies should be implemented according to certain inequity patterns. Consumption-related inequity is mainly explained by the direct effect of per capita annual family consumption for antenatal care and postnatal care. The purchasing power of residents was seen to be the main barrier for utilization of services during pregnancy and after delivery. Living in eastern/middle/western areas and maternal occupation also explained part of the pro-rich inequity of effective coverage of antenatal care. To address to health inequity of maternal and child health interventions, targeting the disadvantage population or universal coverage can be applied. No matter what strategy is chosen, it is essential to build a maternal and child health inequity monitoring and evaluation system to continuously measure the inequity and its influential factors for maternal and child health interventions. Moreover, to identify and prospectively track of high risk population using the data from this maternal and child health inequity monitoring and evaluation system is also needed, which could facilitate evidence-based policy making on closing the gap of maternal and child health.
引文
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