A Study On Equity Of Maternal Health Care Utilization In Putuo District Of Shanghai

BackgroundWHO re-emphasize the value that Health for All and reiterated the necessity to set up the agenda for integration of equity view to the formulation of public and health policies in For the 21 Century Primary Health Care Assembly held at Alma-Ata in 1998. China is ranked at 188, which is fourth from bottom, according to the estimation of WHO according to equity of health burden and was one of the world's most inequitable countries. Nowadays in China, especially in those remote rural areas, the utilization of maternal health care remains low due to limitation of social-economic development. National-wide, Maternal Mortality Ratio (MMR) in China is far higher than developed countries of Europe and North American. Recent years, the MMR changes up and down, declines slows down, and the gaps between regions further increases within country. With economic development after reformation and opening policies, lots of immigration to Shanghai leads rapid increase of number of delivery and related maternal death in this population in Shanghai. Data shows Maternal Mortality Ratio of migrant women are 5 times higher than their local counterpart.ObjectivesTo describe utilizations and financing of Maternal Health Care among local and migrant women in Putuo District, and to identify the gap between them. To analyses factors associated the utilization and financing of Maternal Health Care of migrant and local maternity in Putuo District. To recommend the policies to ameliorate the equity of Maternal Heath Care.MethodsBoth quantitative and qualitative methods were used in the study. Questionnaire survey was carried out among lying-in women to obtain information on utilization of maternal health care and their financing. Data established the database by Ep ida ta2.1 and Statistical anlysised by SP SS11.0. Qualitative data were also gathered through in-depth interview to further identify and analyses factors and main obstacles which influenced the utilization of maternal health care. Listened and read the records of in-depth interview repeatedly.Summarized the suggestion from the information of interview.Results 1. General information of target population, their husbands and families1.1 Demographic characteristics of target populationIn the survey, the age of most local lying-in women was between 25 and 34 years old. Most of them registered as non-agriculture household, with holding college diploma or bachelor degree and having income higher than 3000 Yuan per month.86.46% were covered by medical insurance. Meanwhile the age of most migrant ones was in the same interval of their local counterparts. Half of them registered as agriculture household, with most of them holding diploma on senior high school or secondary school and having income lower than 3000 Yuan per month.32.68% were covered by medical insurance. The difference of the two groups had statistical significance on all those aspects.1.2 Demographic characteristics of the husbandsIn the survey husbands'age of most local lying-in women was between 25 and 34 years old with registered as non-agriculture household and holding college diploma or bachelor degree. Meanwhile the husbands'age of most migrant was in the same interval of their local counterpart with registered as non-agriculture household and received education maximum till senior high or secondary school. The difference of the two groups had statistical significance on all those aspects.1.3 Family incomeIn the survey family incomes of most local lying-in women were more than 5000 Yuan per month and lived in their own apartments. Family incomes of most migrant ones were less than 5000 Yuan, and half of them lived in rented-habitation. The difference of the two groups had statistical significance.1.4 Fertility information of target populationMost of local lying-in women in the survey were primipara with more than 70% planned this pregnancy. Roughly 20% migrant ones were multiparous with more than 60% planned this pregnancy. The difference of the two groups had statistical significance.2. Utilization of maternal health services2.1 Utilization of pre-pregnancy careIn the survey 59.88% local lying-in women received premarital health check-up, with meanwhile, only 47.94% migrant ones received. The difference of the two groups had statistical significance.In the survey, roughly 40% local and migrant lying-in women received pre-natal care. The difference of the two groups hadn't statistical significance.2.2 Utilization of pre-natal careIn the survey 90.28% local lying-in women registered in first level hospital with 76.99% done this at early stage of the pregnancy.83.23% completed full pre-natal health check-up with 65.20% in second level hospitals.81.93% had attended lectures in Pregnancy School. Meanwhile only 52.85% migrant ones registered in first level hospital with 49.86% done this at early stage of the pregnancy.59.33% completed full pre-natal health check-up with 77.97% in second level hospitals.55.72% of the migrant had attended lectures in Pregnancy School. The difference of the two groups had statistical significance in all these aspects.2.3 Utilization of intra-partum servicesIn the survey all lying-in women had hospitalized delivery.64.78% of local women chose to have their babies at second level hospital with 60.12% by caesarean section. The average gestational age (±2SD) of local ones was 38.890±1.2890 weeks and average birth weight of new born(±2SD) was 3378.65(±455.965) gram. Meanwhile 77.91% of the migrant ones chose to deliver their babies at second level hospital with 52.53% normal delivery. The average gestational age(±2SD) of them was 39.079±1.3742 weeks and average birth weight of newborn(±2SD)was 3359.34±488.828 gram.The difference of the two groups had statistical significance in level of hospital delivered, mode of delivery, gestational age due to delivery (P<0.05). The difference of the newborn birth weight of two groups hadn't statistical significance.2.4 Utilization of post-natal careIn the survey, more than half of local lying-in women stayed in the wards occupied with 1-2 persons per room with most of them for 3-6 days. Almost all of them received postnatal visits. Meanwhile around 60% migrant ones stayed in the wards occupied more than 3 persons per room with most of them for less than 4 days. Roughly 70% of them received postnatal visit.The difference of the two groups had statistical significance in percentage of staying different type of postpartum wards, days in wards after delivery and receiving postnatal visit.3. Financing of maternal health servicesIn the survey most of local lying-in women had spent 1000 to 4999 Yuan on prenatal health check-up. Roughly 60% of them paid more than 5000 Yuan for their hospitalized delivery. Meanwhile most of the migrant had spent less than 3000 Yuan. Roughly 60% of them paid less than 5000 Yuan for their hospitalized delivery. The difference of the two groups had statistical significance in average cost of prenatal health check-up and hospitalized delivery.4. Factors associated utilization and financing of maternal health care4.1 Factors associated utilization of maternal health careDichotomous Logistic Regression Analysis showed:factors associated registered at early pregnancy or not included age of lying-in women, household registration of women and her husband, education of husband, premarital health check-up or not; factors associated full prenatal health check-up or not included age of lying-in women, household register of husband, family income; factors associated attending Pregnancy School or not included age of lying-in women, household registration of husband, number of delivery, situation of family habitation; factors associated receiving postpartum visit or not included household registration of husband, situation of family habitation.4.2 Factors associated financing of maternal health careOrdinal Logistic Regression Analysis showed:factors associated expenses of prenatal health check-up included monthly income of lying-in women, monthly income of family; factors associated expenses of hospitalized delivery included mode of delivery, type of postpartum wards, days hospitalized after birth, type of hospital delivered babies.Conclusions1. Migrant lying-in women characterized with lower education, economic situation and health insurance coverage. The percentage of multiparous among them was higher. Comparing with the local ones, the migrant had lower education, family income, medical insurance coverage, and worse family habitation.2. The difference of utilization of Maternal Health Care between migrant lying-in women and the local ones indicated in-equity. Migrant had lower percentage of registration at early pregnancy, full prenatal health check-up, Pregnancy School attendance, wards staying after birth, postnatal visit and more of them registered at lower level hospital. The difference was roughly 10-40%.3. In-equity of Maternal Health Care financing between the lying-in migrant women and the local ones exists.There was no significant difference between migrant lying-in women with the local ones on expenses of prenatal health check-up and hospitalized delivery. But the medical insurance coverage of the migrant was lower which indicated inequity on financing of maternal health care.4. Utilization and financing of Maternal Health Care were influenced by multiple factors.The utilization and financing of Maternal Health Care influenced by age of maternity, husbands'household registration, economic status, mode of delivery, distribution of health services, based on quantitative and qualitative study.Suggestions1. Governments should increase coverage of medical insurance and establish national-wide insurance network.2. Health authorities should enhance publicity to improve the accessibility of health services.3. Further analysis-is needed to identify why cesarean section increased among migrant women.4. It is necessary to explore suitable Health Education Model for migrant women.5. It is particularly important that suitable health education purposefully delivered to pregnant women elder than 35 year-old for their different pregnant stage.6. It is urgent to establish fertility fund for migrant women.