Skip to main content

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

Abstract

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.

Peer Review reports

Background

Maternal death remains a major global concern. Reducing maternal mortality ratio (MMR) is a priority goal on the international agenda [1]. Maternal mortality ratio is an important health indicator that can be used in making comparisons across different time periods and geographic regions [2]. Millennium Development Goal 5 was launched by members of the United Nations (UN)—its aim was to reduce the MMR by three-quarters between 1990 and 2015 [3,4,5]. During this period, China achieved the goal set by Millennium Development Goal 5 [6]. In 2015, all UN member states set the Sustainable Development Goal which aims at reduce the MMR to 70.0 per 100,000 live births by 2030 [7]. In 2016, the Chinese government proposed the Healthy China 2030 plan, which aimed to reduce the MMR to 18.0/100,000 births by 2020 and 12.0/100,000 births by 2030 [8]. This plan puts forward higher requirements for maternal health than proposed by the UN.

In the past three decades, China had launched several public health programs that are beneficial to maternal health, such as the Basic Public Health Service Equalization, Maternal Mortality Reduction and Neonatal Tetanus Elimination Program, Urban Employees Basic Medical Insurance, Five Strategies for Maternal and Newborn Safety, New Cooperative Medical Scheme, and Urban Residents Basic Medical Insurance [9,10,11,12]. After China implemented the Two-Child policy in 2013, the number of live births and the proportion of high-risk pregnancies increased, making it challenging to achieve the MMR target in the Healthy China 2030 plan [13, 14]. The main causes of maternal death include obstetric hemorrhage, puerperal infection, amniotic fluid embolism, pregnancy-induced hypertension, liver disease, and heart disease, which are mostly preventable [15]. Hospital delivery means that pregnant women give birth in hospital, which is an effective strategy to prevent maternal and infant deaths [16].

The total health expenditure (THE) is the total amount of money in currency consumed by the whole society for health services in a region or country in a certain period [17]. It includes government health expenditure (GHE), social health expenditure (SHE) and out-of-pocket health expenditure (OOPHE). THE can reflect the relationship between health policies and economic development, and provide information for the government to formulate health strategies. SHE is mainly composed of two parts: basic medical insurance fund and social capital investment paid by units and individuals [17]. The proportion of OOPHE is positively correlated with underdevelopment and social injustice [18, 19]. Health status is not only related to the amount of THE, but also the structure among the three components [20].

Although several studies have investigated the MMR in China, these studies were limited to certain areas [21,22,23] or short periods of time [24,25,26]. Further, there was a lack of research on the correlation between MMR and health financing composition. In this study, we aimed to assess the trends of MMR, the main causes of maternal death, and the correlations between MMR and total health financing composition in China from 1990 to 2019.

Methods

Definitions

Maternal deaths are defined as deaths of women who are pregnant or are within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes [27]. MMR is defined as the number of maternal deaths per 100,000 live births.

Data sources

We conducted a longitudinal study. Data on the MMR, main causes of maternal death, hospital delivery rate, THE, CHE, SHE, and OOPHE from 1990 to 2019 were collected from the China Health Statistics Yearbooks (1991–2020). Data on per capita annual income from 1990 to 2019 came from the China Statistical Yearbook 2020.

To monitor the maternal deaths in China, National Maternal Mortality Surveillance System (NMMSS) was set up by the Chinese government in 1989. The sampling unit of NMMSS is at the county (district) level [9, 28]. In total, 336 surveillance spots (126 in urban areas and 210 in rural areas) across 31 provinces in mainland China were selected to record changes in MMR and the main causes of maternal death. The NMMSS has rigorous quality control mechanisms, including data audits, regular supervision, and standardization of data collection methods. Data on live births and maternal death are collected annually by trained officials and verified by government administrators before being included in the China Health Statistics Yearbooks [24].

Statistical analysis

We analyzed the time series data using linear regression analysis to assess the trends in the MMR in China from 1990 to 2019 [9]. Pearson correlation analysis was used to assess the associations between the national MMR and China’s total health financing composition. All analyses in this study were conducted using Statistical Product and Service Solutions version 19, and a two-sided p value of < 0.01 was considered significant.

Results

The national MMR decreased by 80.0% from 88.9 per 100,000 live births in 1990 to 17.8 per 100,000 live births in 2019 (Fig. 1). Between 1990 and 2019, the rural MMR declined from 112.5 per 1000 livebirths to 18.6 per 1000 livebirths—a drop of 83.5%. The urban MMR decreased by 64.1% from 45.9 per 100,000 live births in 1990 to 16.5 per 100,000 live births in 2019. The MMR in rural areas was approximately twice (112.5 / 45.9 = 2.4) that in urban areas in 1990, and the difference between them (18.6 / 16.5 = 1.1) was relatively small in 2019. The per capita annual income of urban residents was 2.2 times (1510 / 686 = 2.2) that of rural residents in 1990, and it was 2.6 times (42,359 / 16,021 = 2.6) that of rural residents in 2019.

Fig. 1
figure1

Maternal mortality ratio and per capita annual income in China from 1990 to 2019

The results of the linear regression analysis of the national MMR showed that the coefficient was − 2.290 (95%CI: − 2.461, − 0.79; p < 0.01) and the intercept was 4635.412 (95%CI: 4292.435, 4978.389; p < 0.01). The trend of the yearly national MMR was − 2.290, which indicates a yearly decline of 2.290 maternal deaths per 100,000 livebirths. The results of linear regression analysis of the rural MMR showed that the coefficient was − 3.167 (95%CI: − 3.437, − 2.898; p < 0.01) and the intercept was 6403.053 (95%CI: 5863.390, 6942.717; p < 0.01), which indicates a yearly decline of 3.167 rural maternal deaths per 100,000 livebirths. The results of linear regression analysis of the urban MMR showed that the coefficient was − 0.901 (95%CI: − 1.070, − 0.731; p < 0.01) and the intercept was 1834.014 (95%CI: 1494.680, 2173.348; p < 0.01), which indicates a yearly decline of 0.901 urban maternal deaths per 100,000 livebirths.

The national MMR caused by puerperal infection dropped by 93.2% from 4.4 per 100,000 live births in 1990 to 0.3 per 100,000 live births in 2019 (Fig. 2); the national MMR caused by obstetric hemorrhage dropped by 91.7% from 36.3 per 100,000 live births in 1990 to 3.0 per 100,000 live births in 2019; the national MMR caused by liver disease dropped by 85.7% from 2.8 (1990) to 0.4 (2019). From 1990 to 2019, the national MMR caused by pregnancy-related hypertension, amniotic fluid embolism, and heart disease dropped by 73.3, 62.5, and 60.6%, respectively. The mortalities for the main causes of maternal death all decreased from 1990 to 2019. The national MMR caused by obstetric hemorrhage was 3.0 per 100,000 live births in 2019, which is the leading cause of maternal death nationwide. The leading cause of maternal death in urban areas was heart disease (3.3 per 100,000 live births) in 2019, while that in rural areas was obstetric hemorrhage (3.8 per 100,000 live births). The hospital delivery rate in China increased, with almost all pregnant women giving birth in hospitals in 2019 (Fig. 3). The hospital delivery rate in urban areas was 1.65 times (74.2 / 45.1 = 1.65) that in rural areas in 1990, and it was almost equal in urban and rural areas in 2019. The gap in hospital delivery rate between urban and rural areas declined gradually from 1990 to 2019.

Fig. 2
figure2

Maternal mortality ratio from main causes of pregnancy-related death in China, 1990–2019

Fig. 3
figure3

Hospital delivery rate in China from 1990 to 2019

The absolute number of THE, GHE, SHE and OOPHE increased in China from 1990 to 2019 (Table 1). The proportion of GHE and SHE in THE increased by 9.2 and 12.9% from 1990 to 2019, respectively. The proportion of OOPHE in THE decreased by 20.6% from 35.73% in 1990 to 28.36% in 2019. Pearson correlation analysis results showed that national MMR was negatively correlated with the absolute number of THE, GHE, SHE and OOPHE (p < 0.01). National MMR was negatively correlated with the proportion of THE in GDP (r = − 0.848, p < 0.01), and the proportion of GHE in THE (r = − 0.667, p < 0.01). There was a positive correlation between the national MMR and proportion of OOPHE in THE (r = 0.516, p < 0.01). National MMR was not significantly correlated with the proportion of SHE in THE (r = − 0.288, p = 0.122).

Table 1 Pearson correlations between national maternal mortality ratio and total health financing composition

Discussion

MMR is a universally accepted indicator to measure the status of a nation’s health and economic systems. This study assessed the trends of MMR, the main causes of maternal death, and the correlations between MMR and total health financing composition.

Although the gap in per capita annual income between the rural and urban areas widened from 1990 to 2019, the gap in MMR between them narrowed. This may be due to the improvement in medical services in rural areas [10]. Urbanization may be another reason for this phenomenon. With the emergence of urbanization, part of the rural population moved to cities. The economic status, health awareness, and educational background of this population are relatively low [29]. The MMRs in rural and urban areas were almost equal in 2010. This phenomenon may resulted from the implementation of the Basic Public Health Service Equalization project by Chinese government in 2009, which aimed to equalize public health services and improve the quality of life of all urban and rural residents [30]. The MMR in rural areas in China fluctuated between 1990 and 2002. After the implementation of the New Cooperative Medical Scheme in 2003, the MMR in rural areas steadily decreased from 2003 to 2019. The Chinese government carried out insurance and health care reform, resulting in more than 90% of the population having some medical insurance [31, 32]. These measures have likely helped to improve the maternal survival of Chinese women.

The mortalities caused by the main maternal diseases all declined from 1990 to 2019, which may be due to the improvement of healthcare conditions in China. The decline in mortality caused by obstetric hemorrhage seems to be an important contributor in the decline in maternal mortality in China. Prevention of obstetric hemorrhage is important for improving the survival rate of pregnant women. Measures to reduce the risk of obstetric hemorrhage include antenatal care, skilled delivery, emergency obstetric care, and postpartum care. These measures are more effective when combined with hospital delivery. Promoting hospital delivery is a very effective measure to reduce the risk of pregnancy-related diseases, especially in developing countries where many women traditionally give birth at home [33].

The proportion of OOPHE is positively correlated with underdevelopment and social injustice [18, 19]. Increasing the proportion of OOPHE may cause people to be unable to access care and may further compromise their financial security [34,35,36]. OOPHE always accounts for a large proportion of THE in developing countries [37]. Governmental health spending can effectively reduce the burden of OOPHE at the household level [38]. Although the proportion of OOPHE in THE decreased in China, China still has one of the highest OOPHE rates in Asia [18, 39]. The implementation of the zero-markup policy for essential drugs in China did lead to a decrease in cost of prescription drugs but has led to rising costs other hospital and health expenditure costs, so the actual OOPHE of patients is still very high [40]. Compared with developed countries, the proportion of GHE in THE in China was far less than the United States, Japan, Canada and Italy (all above 40%) [17]. In the case of limited GHE, SHE should be increased to alleviate the problem of “expensive medical service”. It is important to transfer individual medical burden and ensure the source of social funds as a safety net. Chinese government should expand the coverage of serious disease insurance, strengthen the construction of the medical security system, increase the reimbursement ratio, and include more safe and effective drugs in the national basic medical insurance drug list to reduce the burden of personal medical expenses.

In the past three decades, China has implemented various public health programs for maternal healthcare [41]. The Basic Public Health Service Equalization project was launched in 2009. This project aimed to equalize public health services and improve the quality of life of all urban and rural residents [30]. This project has numerous objectives, one of which is improving the quality of maternal health services. Specific measures included the establishment of maternal health records, prenatal examinations, and postnatal visits for rural and urban pregnant women. For example, maternal health providers were trained according to national standards and were required to deliver the same quality of maternal health services to rural and urban women [9]. The Maternal Mortality Reduction and Neonatal Tetanus Elimination program was implemented in 378 counties in 12 western provinces in 1999, expanding coverage to 2288 counties in 22 central and western provinces from 2008. This program effectively reduced the maternal mortality rate through the improvement of hospital delivery, and it was implemented at the national level to ensure free hospital delivery for all women in China in 2009 [10]. This program was composed of the following five strategies: pregnancy risk screening and assessment, case-by-case management, referral and treatment, reporting for maternal deaths, and accountability strategies [14]. The Urban Employees Basic Medical Insurance, Urban Residents Basic Medical Insurance, and New Cooperative Medical Scheme were health insurance programs funded by central and local governments and donations from individuals. The Urban Employees Basic Medical Insurance was a compulsory health insurance launched in 1999 for employees and employers in urban areas. However, older adults, children, students, and unemployed individuals who moved to urban areas from rural areas were not included in the Urban Employees Basic Medical Insurance system. Therefore, to address this problem, the Urban Residents Basic Medical Insurance scheme was established in 2007, and the scheme improved the healthcare services provided to some groups and reduced healthcare inequalities [11]. The New Cooperative Medical Scheme offered subsidies for rural residents working in antenatal and postnatal facilities and encouraged hospital delivery, either as a prepayment or retrospective reimbursement [42].

This study has some limitations. Data on maternal deaths in some extremely remote areas may not be registered. The quality of surveillance systems and data may differ across regions. Research has reported discrepancies between routine data and survey data on the number of reported live births and child and maternal mortality, and the quality of routine data in urban areas was better than in rural areas [43].

Conclusions

China has made remarkable progress in improving maternal survival, especially in rural areas. The gap in MMR between rural and urban areas has narrowed substantially. To achieve the goal set by the Healthy China 2030 and further decrease the MMR, 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, strengthen the medical security system, reduce income inequality, and allocate resources more rationally.

Availability of data and materials

The dataset generated and analyzed during the current study is available in the official website of National Health Commission of the People’s Republic of China. (http://www.nhc.gov.cn), and the public access to this dataset is open. The dataset is also available from the corresponding author on reasonable request.

Abbreviations

MMR:

Maternal mortality ratio

UN:

United Nation

GDP:

Gross domestic product

NMMSS:

National maternal mortality surveillance system

THE:

Total health expenditure

GHE:

Government health expenditure

OOPHE:

Out-of-pocket health expenditure

SHE:

Social health expenditure

References

  1. 1.

    Mgawadere F, Kana T, van den Broek N. Measuring maternal mortality: a systematic review of methods used to obtain estimates of the maternal mortality ratio (MMR) in low- and middle-income countries. Br Med Bull. 2017;121(1):121–34. https://0-doi-org.brum.beds.ac.uk/10.1093/bmb/ldw056.

    Article  PubMed  PubMed Central  Google Scholar 

  2. 2.

    Collier AY, Molina RL. Maternal mortality in the United States: updates on trends, causes, and solutions. NeoReviews. 2019;20(10):e561–74. https://0-doi-org.brum.beds.ac.uk/10.1542/neo.20-10-e561.

    Article  PubMed  PubMed Central  Google Scholar 

  3. 3.

    Nielsen HS, Eggebø TM. Millennium development goal 5--an obstetric challenge. Acta Obstet Gynecol Scand. 2012;91(9):1007–8. https://0-doi-org.brum.beds.ac.uk/10.1111/j.1600-0412.2012.01505.x.

    Article  PubMed  Google Scholar 

  4. 4.

    Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, et al. Maternal mortality for 181 countries, 1980-2008: A systematic analysis of progress towards millennium development goal 5. Lancet (London, England). 2010;375(9726):1609–23.

    Article  Google Scholar 

  5. 5.

    Sachs JD, McArthur JW. The millennium project: a plan for meeting the millennium development goals. Lancet (London, England). 2005;365(9456):347–53.

    CAS  Article  Google Scholar 

  6. 6.

    Global, regional, and national age-sex specific mortality for 264 causes of death, 1980–2016. A systematic analysis for the global burden of disease study 2016. Lancet (London, England). 2017;390(10100):1151–210.

    Article  Google Scholar 

  7. 7.

    Callister LC, Edwards JE. Sustainable development goals and the ongoing process of reducing maternal mortality. J Obstet Gynecol Neonatal Nurs. 2017;46(3):e56–64. https://0-doi-org.brum.beds.ac.uk/10.1016/j.jogn.2016.10.009.

    Article  PubMed  Google Scholar 

  8. 8.

    Tan X, Zhang Y, Shao H. Healthy China 2030, a breakthrough for improving health. Glob Health Promot. 2019;26(4):96–9. https://0-doi-org.brum.beds.ac.uk/10.1177/1757975917743533.

    Article  PubMed  Google Scholar 

  9. 9.

    Zhao P, Diao Y, You L, Wu S, Yang L, Liu Y. The influence of basic public health service project on maternal health services: an interrupted time series study. BMC Public Health. 2019;19(1):824. https://0-doi-org.brum.beds.ac.uk/10.1186/s12889-019-7207-1.

    Article  PubMed  PubMed Central  Google Scholar 

  10. 10.

    Feng XL, Shi G, Wang Y, Xu L, Luo H, Shen J, et al. An impact evaluation of the safe motherhood program in China. Health Econ. 2010;19(Suppl):69–94. https://0-doi-org.brum.beds.ac.uk/10.1002/hec.1593.

    Article  PubMed  Google Scholar 

  11. 11.

    Xian W, Xu X, Li J, Sun J, Fu H, Wu S, et al. Health care inequality under different medical insurance schemes in a socioeconomically underdeveloped region of China: a propensity score matching analysis. BMC Public Health. 2019;19(1):1373. https://0-doi-org.brum.beds.ac.uk/10.1186/s12889-019-7761-6.

    Article  PubMed  PubMed Central  Google Scholar 

  12. 12.

    Li J, Huang Y, Nicholas S, Wang J. China's new cooperative medical scheme's impact on the medical expenses of elderly rural migrants. Int J Environ Res Public Health. 2019;16(24). https://0-doi-org.brum.beds.ac.uk/10.3390/antiox8050112.

  13. 13.

    Li HT, Xue M, Hellerstein S, Cai Y, Gao Y, Zhang Y, et al. Association of China's universal two child policy with changes in births and birth related health factors: national, descriptive comparative study. BMJ. 2019;366:l4680.

    Article  Google Scholar 

  14. 14.

    Liu J, Song L, Qiu J, Jing W, Wang L, Dai Y, et al. Reducing maternal mortality in China in the era of the two-child policy. BMJ Glob Health. 2020;5(2):e002157. https://0-doi-org.brum.beds.ac.uk/10.1136/bmjgh-2019-002157.

    Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet (London, England). 2006;367(9516):1066–74.

    Article  Google Scholar 

  16. 16.

    Fan X, Xu Y, Stewart M, Zhou Z, Dang S, Wang D, et al. Effect of China's maternal health policy on improving rural hospital delivery: evidence from two cross-sectional surveys. Sci Rep. 2018;8(1):12326. https://0-doi-org.brum.beds.ac.uk/10.1038/s41598-018-29830-8.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Zheng A, Fang Q, Zhu Y, Jiang C, Jin F, Wang X. An application of ARIMA model for predicting total health expenditure in China from 1978-2022. J Glob Health. 2020;10(1):010803. https://0-doi-org.brum.beds.ac.uk/10.7189/jogh.10.010803.

    Article  PubMed  PubMed Central  Google Scholar 

  18. 18.

    Zhang D, Rahman KMA. Government health expenditure, out-of-pocket payment and social inequality: a cross-national analysis of China and OECD countries. Int J Health Plann Manag. 2020;35(5):1111–26. https://0-doi-org.brum.beds.ac.uk/10.1002/hpm.3017.

    Article  Google Scholar 

  19. 19.

    Younsi M, Chakroun M, Nafla A. Robust analysis of the determinants of healthcare expenditure growth: evidence from panel data for low-, middle- and high-income countries. Int J Health Plann Manag. 2016;31(4):580–601. https://0-doi-org.brum.beds.ac.uk/10.1002/hpm.2358.

    Article  Google Scholar 

  20. 20.

    Wang X, Sun Y, Mu X, Guan L, Li J. How to improve the equity of health financial sources? - simulation and analysis of total health expenditure of one Chinese province on system dynamics. Int J Equity Health. 2015;14(1):73. https://0-doi-org.brum.beds.ac.uk/10.1186/s12939-015-0203-x.

    Article  PubMed  PubMed Central  Google Scholar 

  21. 21.

    Wang Y, Shen Z, Jiang Y. Analyzing maternal mortality rate in rural China by Grey-Markov model. Medicine. 2019;98(6):e14384. https://0-doi-org.brum.beds.ac.uk/10.1097/MD.0000000000014384.

    Article  PubMed  PubMed Central  Google Scholar 

  22. 22.

    Gyaltsen Gongque Jianzan K, Gyal Li Xianjia L, Gipson JD, Kyi Cai Rangji T, Pebley AR. Reducing high maternal mortality rates in western China: a novel approach. Reprod Health Matters. 2014;22(44):164–73.

    Article  Google Scholar 

  23. 23.

    Zheng XY, Yi Q, Xu YJ, Zeng XY, Xu XJ, Chen G, et al. Health transition of the causes of mortality between 2005 and 2015 in Guangdong, China. Postgrad Med J. 2021:postgradmedj-2020-139269. https://0-doi-org.brum.beds.ac.uk/10.1136/postgradmedj-2020-139269.

  24. 24.

    Zhao P, Han X, You L, Zhao Y, Yang L, Liu Y. Maternal health services utilization and maternal mortality in China: a longitudinal study from 2009 to 2016. BMC Pregnancy Childbirth. 2020;20(1):220. https://0-doi-org.brum.beds.ac.uk/10.1186/s12884-020-02900-4.

    Article  PubMed  PubMed Central  Google Scholar 

  25. 25.

    Zhou M, Liu S, Kate Bundorf M, Eggleston K, Zhou S. Mortality in rural China declined as health insurance coverage increased, but no evidence the two are linked. Health Aff (Millwood). 2017;36(9):1672–8. https://0-doi-org.brum.beds.ac.uk/10.1377/hlthaff.2017.0135.

    Article  Google Scholar 

  26. 26.

    Tian F, Pan J. Hospital bed supply and inequality as determinants of maternal mortality in China between 2004 and 2016. Int J Equity Health. 2021;20(1):51. https://0-doi-org.brum.beds.ac.uk/10.1186/s12939-021-01391-9.

    Article  PubMed  PubMed Central  Google Scholar 

  27. 27.

    Kodan LR, Verschueren KJC, McCaw-Binns AM, Tjon Kon Fat R, Browne JL, Rijken MJ, et al. Classifying maternal deaths in Suriname using WHO ICD-MM: different interpretation by physicians, national and international maternal death review committees. Reprod Health. 2021;18(1):46. https://0-doi-org.brum.beds.ac.uk/10.1186/s12978-020-01051-1.

    Article  PubMed  PubMed Central  Google Scholar 

  28. 28.

    Gan XL, Hao CL, Dong XJ, Alexander S, Dramaix MW, Hu LN, et al. Provincial maternal mortality surveillance systems in China. Biomed Res Int. 2014;2014:187896.

    PubMed  PubMed Central  Google Scholar 

  29. 29.

    Zhou Y, Wang T, Fu J, Chen M, Meng Y, Luo Y. Access to reproductive health services among the female floating population of childbearing age: a cross-sectional study in Changsha, China. BMC Health Serv Res. 2019;19(1):540. https://0-doi-org.brum.beds.ac.uk/10.1186/s12913-019-4334-4.

    Article  PubMed  PubMed Central  Google Scholar 

  30. 30.

    Li X, Cochran C, Lu J, Shen J, Hao C, Wang Y, et al. Understanding the shortage of village doctors in China and solutions under the policy of basic public health service equalization: evidence from Changzhou. Int J Health Plann Manag. 2015;30(1):E42–55. https://0-doi-org.brum.beds.ac.uk/10.1002/hpm.2258.

    Article  Google Scholar 

  31. 31.

    Liu Y, Yuan Z, Liu Y, Jayasinghe UW, Harris MF. Changing community health service delivery in economically less-developed rural areas in China: impact on service use and satisfaction. BMJ Open. 2014;4(2):e004148. https://0-doi-org.brum.beds.ac.uk/10.1136/bmjopen-2013-004148.

    Article  PubMed  PubMed Central  Google Scholar 

  32. 32.

    Meng Q, Xu L, Zhang Y, Qian J, Cai M, Xin Y, et al. Trends in access to health services and financial protection in China between 2003 And 2011: a cross-sectional study. Lancet (London, England). 2012;379(9818):805–14.

    Article  Google Scholar 

  33. 33.

    Li X, Zhu J, Dai L, Li Q, Li W, Zeng W, et al. Hospitalized delivery and maternal deaths from obstetric hemorrhage in China from 1996 to 2006. Acta Obstet Gynecol Scand. 2011;90(6):586–92. https://0-doi-org.brum.beds.ac.uk/10.1111/j.1600-0412.2011.01110.x.

    Article  PubMed  Google Scholar 

  34. 34.

    Bremer P. Forgone care and financial burden due to out-of-pocket payments within the German health care system. Heal Econ Rev. 2014;4(1):36. https://0-doi-org.brum.beds.ac.uk/10.1186/s13561-014-0036-0.

    Article  Google Scholar 

  35. 35.

    Grande D, Barg FK, Johnson S, Cannuscio CC. Life disruptions for midlife and older adults with high out-of-pocket health expenditures. Ann Fam Med. 2013;11(1):37–42. https://0-doi-org.brum.beds.ac.uk/10.1370/afm.1444.

    Article  PubMed  PubMed Central  Google Scholar 

  36. 36.

    Onah MN, Govender V. Out-of-pocket payments, health care access and utilisation in South-Eastern Nigeria: a gender perspective. PLoS One. 2014;9(4):e93887. https://0-doi-org.brum.beds.ac.uk/10.1371/journal.pone.0093887.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  37. 37.

    Qin X, Luo H, Feng J, Li Y, Wei B, Feng Q. Equity in health financing of Guangxi after China's universal health coverage: evidence based on health expenditure comparison in rural Guangxi Zhuang autonomous region from 2009 to 2013. Int J Equity Health. 2017;16(1):174. https://0-doi-org.brum.beds.ac.uk/10.1186/s12939-017-0669-9.

    Article  PubMed  PubMed Central  Google Scholar 

  38. 38.

    McIntyre D, Meheus F, Røttingen JA. What level of domestic government health expenditure should we aspire to for universal health coverage? Health Econ Policy Law. 2017;12(2):125–37. https://0-doi-org.brum.beds.ac.uk/10.1017/S1744133116000414.

    Article  PubMed  Google Scholar 

  39. 39.

    Yip W, Hsiao WC. The Chinese health system at a crossroads. Health Aff (Millwood). 2008;27(2):460–8. https://0-doi-org.brum.beds.ac.uk/10.1377/hlthaff.27.2.460.

    CAS  Article  Google Scholar 

  40. 40.

    Liu S, Xu H, Cui X, Qian Y. How the implementation of drug zero markup policy will affect health care expenditure in hospitals: observation and prediction based on Zhejiang model. Value Health. 2014;17(7):A790. https://0-doi-org.brum.beds.ac.uk/10.1016/j.jval.2014.08.432.

    CAS  Article  PubMed  Google Scholar 

  41. 41.

    Li X, Lu J, Hu S, Cheng KK, De Maeseneer J, Meng Q, et al. The primary health-care system in China. Lancet (London, England). 2017;390(10112):2584–94.

    Article  Google Scholar 

  42. 42.

    Long Q, Zhang Y, Raven J, Wu Z, Bogg L, Tang S, et al. Giving birth at a health-care facility in rural China: is it affordable for the poor? Bull World Health Organ. 2011;89(2):144–52. https://0-doi-org.brum.beds.ac.uk/10.2471/BLT.10.079434.

    Article  PubMed  Google Scholar 

  43. 43.

    Du Q, Næss O, Bjertness E, Yang G, Wang L, Kumar BN. Differences in reporting of maternal and child health indicators: a comparison between routine and survey data in Guizhou Province, China. Int J Women's Health. 2012;4:295–303. https://0-doi-org.brum.beds.ac.uk/10.2147/IJWH.S32409.

    Article  Google Scholar 

Download references

Acknowledgements

We thank all the editors of the China Health Statistics Yearbooks (1990-2020) and China Statistical Yearbook 2020. We thank Min Gao, Tiancheng Zhang, Runsi Wang, Suning LI, Liming Tan, Zuolei Chen and reviewers for their helpful advices in improving our manuscript.

Funding

This work was supported by the Projects in the National Key R&D Program of China during the Thirteen Five-Year Plan Period (No. 2018YFC1315303), the CAMS Innovation Fund for Medical Sciences (No. 2017-I2M-1-004), and the Construction of First-class Discipline of Epidemiology and Health Statistics in Fuwai Hospital (No. 2019E-XK09–1).

Author information

Affiliations

Authors

Contributions

LC designed the study and analyzed the data. LC, PF, and LS were involved in manuscript writing. ZW revised the manuscript. All authors have read and approved the manuscript.

Corresponding author

Correspondence to Zengwu Wang.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declared that they have no competing interest.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Chen, L., Feng, P., Shaver, L. et al. Maternal mortality ratio in China from 1990 to 2019: trends, causes and correlations. BMC Public Health 21, 1536 (2021). https://0-doi-org.brum.beds.ac.uk/10.1186/s12889-021-11557-3

Download citation

Keywords

  • Maternal mortality ratio
  • Maternal death
  • Health financing composition
  • Obstetric hemorrhage
  • Hospital delivery rate