Liang J, et al. - Researchers intended to estimate the maternal mortality ratios for 2852 counties in China between 1996 and 2015 using a national registration system of maternal mortality at the county level. The outcomes suggested that maternal mortality ratios have declined rapidly and universally across China at the county level in the past two decades. In even less economically developed places with resource constraints, rapid improvement in maternal mortality ratios is possible. This finding has important implications for improving maternal mortality ratios in the Sustainable Development Goal era in developing countries.

Methods

• Among neighbouring counties, researchers used a state-of-the-art Bayesian small-area estimation hierarchical model with latent Gaussian layers to account for space and time correlations.
• County level estimates were then scaled to be consistent with country-level maternal mortality estimates for China, which were estimated separately from multiple data sources.
• In addition, maternal mortality ratios among ethnic minorities in China and computed Gini coefficients of inequality of maternal mortality ratios at the country and provincial levels were evaluated.

Results

• As a country, China has experienced a rapid decline in maternal mortality ratios, from 108·7 per 100,000 livebirths in 1996 to 21·8 per 100,000 livebirths in 2015, with an annualized rate of decline of 8·5% per year, much faster than the MDG 5 target rate.
• They found, however, substantial heterogeneity in levels and trends at the county level.
• The range of maternal mortality ratios by county in 1996 was 16·8 per 100,000 livebirths in Shantou, Guangdong, to 3510·3 per 100,000 livebirths in Zanda County, Tibet.
• Almost all counties showed a significant decrease in maternal mortality ratios in the two decades, irrespective of 1996.
• The annualized rate of decline across counties between 1996 and 2015 ranges from 4·4% to 12·9% and 2838 (99·5%) of the 2852 counties achieved the MDG 5 pace of decline.
• The decline accelerated from 2005 to 2015 compared to 1996 to 2005.
• The lowest maternal mortality rate in the county was 3·4 per 100,000 livebirths in Nanhu District, Zhejiang Province in 2015.
• The highest still existed in Zanda County, Tibet, but the fall to 830·5 per 100,000 livebirths was only 76·3%.
• In at least one county in China, 26 ethnic groups had population majorities and all had declines in maternal mortality ratios in line with the MDG 5 rate.
• Intercounty Gini coefficients for the maternal mortality ratio in China have decreased at national level, indicating improved equality, while provincial inequality trends varied.