| Objective Assess the relative importance of major socio-economic and health system barriers that the rural women are facing in accessing maternal care and constraints of providers in implementing appropriate and quality maternal care. It also provides policy-maker and health service managers with evidence for the development of informed policy on MCH.Methods (1) Data collection: Both qualitative and quantitative methods of data collection were used. The qualitative methods used were Key informants interview, Focus Group Discussion (FGD) and in-depth interviews. The local key informants and maternal health service providers and users were recruited to carry out Focus group discussion, in-depth interview and key informants interview. Quantitative study was to collect the routine statistic MCH data of health system. Data analysis: Maxqda2 computer software package was used to manage the qualitative data and the framework analysis approach was used to analyze it.Results (1) Present situation of maternal health care: women in rural areas have little consciousness on the health care, resulting to insufficient utility of maternal health care service, which presented as: frequency of antenatal examination can't meet demand; the contents of examination is incomplete, majority of maternal just do ultrasound examination; Accompany with the increase of hospital delivery rate, the cesarean section rate increases year by year; women have excess birth proposed are many, Women with"unapproved births"worry that if they went to the hospitals, they would be discovered by FP, in order to escape from the inspection and penalty of Family planning commission, they prefer private clinics to general hospitals to access antennal care and hospital delivery services; most of migrant women have same characters such as: engaged in hard physical labor, migrant frequently, low education level, lack of health awareness, poor financial situation, all of those factors result in low utilization frequency. (2) Health system factors influencing maternal health care: fund, human resources, facility and equipment, management and supervision, policy on MCH and relationship between health sector and other departments. First of all, MCH fund is insufficient. There are two sources of funds, financial allocation and clinical business revenue which is the major source of MCH fund in rural area, MCH fund providing by government financial takes only a minor part in rural MCH work. According to qualitative interviews, all the heads of township hospital reflected that there was a serious lack of health recurrent budget, the amount of funding received from the county government varied between 9000 RMB to 100000RMB, and there was no specific budget for MCH. Quantitative data shows that the amount of MCH financial allocation and the proportion accounting for health recurrent budget is little, MCH financial allocation of Tongliang in 2005 was only 95,000RMB, accounting for 2.73% of health recurrent budget. Secondly, MCH workers at township and country levels were in short supply; there were usually only one or two full-time MCH workers in each township. Most staffs working in MCH were part-time and were doctors who also worked in other areas, skilled staffs with professional attitudes were few and staff's education level was low with most staff only graduating from technical secondary school. Among 23 interviewed MCH workers of township hospitals, there are only 3 full-time MCH workers, and other 20 are gynecologists and obstetricians and nurses.There were very few opportunities for training and they had to pay for the training. Thirdly, lacking of effective rewards and punishments mechanism. Although related supervision and management mechanism were setup, which take part on urging MCH workers to finish job in time, due to limited fund, their work enthusiasm can't be mobilized some workers just deal with job, which resulting to the quality of job can't be supervised. Fourthly, basic equipment of obstetrics is shortage; there are only sphygmomanometer, thermometer and stethoscope in some small township hospitals. No separate rooms for examination and treatment, many work carried out in one room. Finally, support for MCH work from all kinds of departments, especially Family Planning department is insufficient, which make the management of Women with"unapproved births"become the difficulty of systemic management of maternal health care.Conclusion Many factors have affects on maternal health care in rural areas, including factors of maternal themselves, socio-economic factors and health system factors. This study emphasize on factors of health system study, among them, fund takes the most important part in affecting MCH, inadequate financial support results in the shortage of MCH workers, poor facility and equipments, and low income of MCH workers. In addition, the management and supervision is imperfect, and lacking of policy related to maternal health care, all of above factors influence the provision and utilization of maternal health care. Aiming at current situation, such measures are imperative: the government needs to pay more attention to maternal health and increase invests to MCH; establish a high-quality, professional and stable team; perfect rural three-tier health care network; cooperate with FP department to develop new flat roof of MCH services.
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