Secular trends of institutional delivery rate in China from 1996 to 2015

Objective: To describe the secular trends of institutional delivery (ID) rate in China from 1996 to 2015 and to assess the impacts of national health policies on the ID rate. Methods: Data on the number of live births and IDs for districts/counties in 31 provinces of China was annually collected by the Office for National Maternal & Child Health Statistics of China. Information concerning the relevant policies was from official governmental websites including the programme to reduce maternal mortality and eliminate neonatal tetanus (2000 to 2008) and ID subsidy programme in rural China (2009 to present). According to the programme to reduce maternal mortality and eliminate neonatal tetanus the calendar years were categorized into three periods: pre-programme period (1996 to 1999) programme implementation period (2000 to 2008) and post-programme period (2009 to 2015). Results: A total of 244 398 010 live births were included in the analysis in which 211 605 727 were delivered in institutions. During the 20 years the ID rate steadily increased from 58.7% (6 309 255/10 739 816) in 1996 to 99.7% (13 583 658/13 626 948) in 2015 with a compound annual growth rate of 2.8%. Analyses stratified by economic regions or urban-rural areas showed notably consistent increases in ID rates and the regional and urban-rural differences became nearly disappeared by 2015. The largest regional difference between East (71.6% 2 540 896/3 547 423) and West (44.6% 1 675 305/3 752 873) was 27% in 1996 and <1% in 2015 (East 99.9%[5 177 865/5 180 636]and West 99.0%[3 925 766/3 964 622]). The urban-rural difference was 22.7% in 1996 (urban 73.5%[2 756 531/3 748 703] rural 50.8%[3 552 724/6 991 113]) and 0.4% in 2015(urban 99.9%[6 257 853/6 262 763] rural 99.5%[7 325 805/7 364 185]). During the programme implementation period and the post-programme period the ID rates in rural area increased faster than those in urban area and the corresponding compound annual growth rates in rural area were 2.4 and 2.8 times of those in urban area; the ID rates in Middle and West regions increased faster than those in East region and the corresponding compound annual growth rates in West region were 3.6 and 6.3 times of those in East region. By 2015 the ID rates in all provinces other than Tibet (90.5%[48 445/53 505]) and Qinghai (97.2%[60 836/62 600]) reached or were close to 100%. However there were still 112 districts/counties with ID rates <96% of which 39 with ID rates <80%; the 39 districts/counties were all located in four western provinces (Tibet 19 Sichuan 15 Qinghai 3 and Xinjiang 2). Conclusions: During the past 20 years the ID rate in China has steadily increased and achieved the goal of the year 2020 ahead of schedule; the regional and urban-rural inequality in ID has nearly disappeared. Given universal two-child policy it is of significance to strengthen existing achievements focus on complicated pregnancies and comprehensively improve the capability and quality of ID services; meanwhile it is also of significance to develop particular policies and explore the medical-aid model for the minority-inhabited western regions with lower ID rates.