| Background:Maternal and Children's Health Care (MCH) in Shanghai has been taking the leading role in China, and the Maternal Mortality Rate (MMR) has been reduced to the level of advanced countries since the implementation of systematic health care for pregnant women from late 70's. With the deepening of economic reform and open-up policies in Shanghai, more and more population are flowing to Shanghai and the number of floating population over 5 million now, which rank the second in China. With the increasing of floating population in Shanghai, the percentage of delivery from floating women among total delivery in Shanghai increased from 4.07% in 1990 to 51.12% in 2005 which brought a lot of difficulties to MCH work especially for systematic maternal health care. The percentage of maternal dealth of floating population increased from 26% in 1990 to 96.87% in 2005. The average MMR of floating population was 5 times (29.55 times in 2005) of those for Shanghai residents in recent 10 years. MMR in Shanghai residents decreased from 22.47/10~5 in 1996 to 1.64/10~5 in 2005, whereas MMR in floating population decreased from 54.68/10~5 to 48.46/105 during the same period. It showed that there was reduced MMR in floating population and Shanghai residents but with the different extent.In order to ensure the safematherhood and reduce MMR, two documents related to the MCH health care and management which titled on "The circular of the enforcement of MCH health management for floating population" and "The circular of the establishment of maternity hospital for floating pregnant women" were issued in 1999 and 2004 respectively. High MMR in floating population with the implementation of 2 related policies has become the great puzzle for the government and health department."Safe motherhood" is the basic reqirement for MCH which proposed by WHO/UNICEF. The issuses related to the survival, protection and development of women and children of floating population has aroused great attention of government and society, "equaled health care services should be provided for floating women" and" the maternal health care for floating population should be included in the maternal health care of flow-in area " were mentioned in 《The Outline for the Women's Development in China (2001-2010) 》 and 《The Outline for Children's Development in China (2001-2010). Facing to the challenge of rapid increase of floating population, it is in urgent need to explore the suitable model of MCH especially the systematic health care for floating pregnant women, so as to further reduce the MMR and ensure the Safe Motherhood in Shanghai.The purpose of this study is to provide the scientific basis for perfecting the related policies of MCH for floating population, by the analysis of situation of health care and dealths in floating population and the evaluation of related policies.Objectives and contents:According to the "barrier"(increasing maternal dealths of floating population) in further reducing MMR in Shanghai, we try to explore the main problems and related influencing factors on maternal health care and management of floating population, and the situation especially the problems and difficulties of implementation of related policies on maternal health care for floating population in Shanghai from different point of views which including health care, administration and policies. The suitable model of maternal health care for floating population in Shanghai will be proposed based on the results of the study which will also be taken as the reference or basis for the modification of relatied policies on maternal health care for floating population.The main contents of the study are as follows:1. to summarize the current model and related polices of maternal health care in Shanghai.2. to analysis the situation of maternal dealths of floating population in Shanghai and make comparison with those of Shanghai residents.3. to study the situation of maternal health care of floating population in Shanghai and make comparison with that of Shanghai residents.4. to evaluate the situation and effects of 10 maternity hospitals for the delivery of floating pregnant women.5. to explore the main problems and difficulties of management for floating population and to analyse the related influencing factors, and to put forword a preliminary model of maternal health care for floating population on the basis of thestudy. MethodsQualitative and quantitative methods, for instance, literature review, expert consultation, focus group discussion, health statistics method, health economic analysis and health policy study are applied to collect the data in this study. The detailed information of applied methods are as follows:Case history review and personal interview have been used to collect the data on the situation of maternal health care of floating population, and the focus group discussion was used to learn the achievements and difficulties of 10 maternity hospitals for floating population. The health statistics methods and health economic methods have been used to analyze the health care demand and utilization of the floating population and Shanghai residents. Besides, the demographic characteristics, economic, community health service status have been analyzed by use the health economic and policy analysis and problems-solving suggestions have been provided. ROCCIPI method is also used to analyse the rule, opportunity, capacity, communication, interest, process and ideology of government, provider and consumer.Main results1. The current model and policies of maternal health care in ShanghaiThe model of maternal health care based on the registered permernant residence which has been used since 1978 in Shanghai. The model has been implemented by following 3 ways: (1) the systematic health care for individual preganct woman, which including the early registration of pregnant women, regular antenatal check-up, hospital delivery, postpartum home visit and health check-up for mother and baby at 42 days of postpartum.(2) for services providers-maternity hospitals and staff, which including the definitude of responsibilities and standards, quality controls,evaluation and feedbacks and training for staff. (3) supporting system, which including the build-up of sound MCH network, pertecting the process of MCH services and making out the corresponding measures for the solving of main problems.There were 11 policies and regulations related to the maternal health care in Shanghai and 2 for floating population.2 The situation of maternal dealths of floating population during 1996-2005 The total number of live births in Shanghai increased 50.38% (from 83208 in 1996 to 125130 in 2005) in recent 10 years, whereas the live births of floating womenincreased 288.67%, from 16458 ( 19.78% of total births) to in 63968(51.12% of total births). The total number of maternal deaths in Shanghai increases from 24 cases in 1996 to 32 cases in 2005,whereas the number of floating maternal dealths increased from 9 cases (37.5% of total deaths) to 31 cases (96.88% of total deaths) . The average MMR was 26.92/10~5 in recent 10 years with the Shanghai residents of 15. 58/10~5 and floating population of 57. 98/10~5 . MMR in Shanghai residents decreased from 22.47/10~5 in 1996 to 1.64/10~5 in 2005, and that of floating population decreased from 54. 68/10~5 to 48. 46/10~5 during the same period. The main causes of floating maternal dealths were direct obstetric causes which accounted for 67.63% whereas those for Shanghai residents were indirect obstetric causes which accounted for 57. 14%. The rank order of causes of maternal dealths was as follows: haemorrage(39.88%), pregnancy induced hypertension (PIH,9.83%) and infection (9.25%), whereas those for Shanghai residents was as follows: haemorrage & ammionic fluid embolism (AFE, 12.86%), heart & hepatic diseases (10%) and ecotopic pregnancy (7. 14%). There are following features of floating maternal dealths: less education, less antenatal check-up and hospital delivery; more paragravida, more pregnancies of extra-planning, and more direct obstetric causes of maternal dealths.3. Study on the situation of health care for floating pregnant women. The registration rate (58.87%) and average gestational weeks of registration (17.71) for floating pregnant women were significantly lower than those of Shanghai residents (97.66%, 12.23). The rate, the first time and number of antenatal health check-up (82.26%, 23.87weeks, 9.09) were significantly lower than those of Shanghai residents (98.13%, 18.04, 5.6). Although the average cost for antenatal check-up was 1109.29 yuan which was significantly lower than that of Shanghai residents (1638.62 yuan) , there were more floating pregnant women complaining the high cost. The emergency hospital admittion rate of floating pregnant women was higher than that of Shanghai residents(56.25%/44.17%). The vaginal delivery rate,average days of hospital stay and cost for delivery were higher than those of Shanghairesidents. The rate of postpartum home visit and health check-up at 42 days after delivery for floating women were significantly lower than those of Shanghai residents. The more incidence of poor pregnancy outcomes in floating population, including the higher incidence of anemia, postpartum haemorrage, low-birth-weight babies and macrosomia, etc.4. The situation of 10 maternity hospitals for floating pregnant womenThe total number of beds in 10 maternity hospitals for floating population expanded from 162 to 257 with the usage rate of 99.6%. The total financial input was 5,895,300 yuan. Total number of births from floating women was 17189 in 10 maternity hospitals which increased 120.60% over the same period of the prior year. There were no maternal dealths and perinatal mortality rate was 4.65‰ which lower than that of the same period of the prior year. The results proved that the policy on setting up the maternity hospital for floating pregnant women was correct and effective.The total number of live births and maternal dealth were 101570 and 32 with the MMR of 31.51/10~5 and 64.31/10~5 for floating population during the same period in the other maternity hospitals except 10 hospitals for floating population.5. The primary model of maternal health care for floating populationOn the basis of experiences from the history of systematic health care in recent 30 years in Shanghai, and according to the weak points and difficulties existed in the management for floating pregnant women, the primary model of maternal health care for floating population was propoased as follows: a new model of maternal health care which based on the living address will replace the old model which based on the registered permanent residence of floationg women reform the system of for individual pregnant woman. Besides, the cooperation of multi-department will be in urgent need.(1) For government, it should take responsibility of providing favourable environment for the management of floating pregnant women, including the policy-making, finiancial support, health education etc.(2) For maternity hospitals, they should play active role in providing services for floating pregnant women with the emphasis on "technique, services and quality"andwith the aim of safemotherhood. Related appropriate technologies should be applied to shorten the hospital stay and save money so as to meet the need of floating pregnant women.(3) For health administration departments, putting emphasis on building-up of 3-level MCH network and the efficient running will be listed as main responsibilities..Conclusions & suggestions1 The model of systematic health care for pregnant women which based on the registered permernant residence has been used since late 70's in Shanghai and has played active role in reducing MMR. With the increasing floating population, the model are facing great challenge of changing population of MCH services. Therefore, it is suggested that a new model which based on the living residence will replace the old one so as to meet the need of maternal health care of floating population .2 Although MMR in Shanghai has show the tendency of decrease, MMR in floating population remains higher level and become the barrier of further reducing MMR in Shanghai. It showed that there was of less maternal health care received by floating population and maternal dealths of floating population with following features: less education, less antenatal check-up and hospital delivery, more births and more postpartum haemorrage . It is suggested that a new system to implement the management for floating pregnant women which including "support and control" from government, "improved quality, convenient service with affordable coast" for maternity hospital and "running of related programs " for health administrative departments.3 The achivements of 10 maternity hospitals for floating population has proved the justice of the policy . But it's necessary to improve the policy and to expand the more similar hospitals to meet the need for rapid increasing floating pregnant women.. Besides, it's in urgent need to ensure the antenatal check-up of floating pregnant women with the establishment of related hospitals .Innovative points of this study:It's the first time to apply the ROCCIPI method to MCH. The study has clarified the difficulties and problems and its related factors in the management offloating pregnant women. On the basis of the analysis, some suggestions have been proposed to perfect the policies on the management of floating pregnant women. The study has also clarified the main causes and related factors of maternal deaths by comparison with Shanghai residents. It has proved the justice and effectiveness of setting up 10 maternity hospitals for floating pregnant women which enable the high MMR in floating population to approach that of Shanghai residents.
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