High maternal and under-five mortality in an ethnic minority predominant area in rural China: a mixed-methods study exploring mother and health-provider experiences

Abstract

Background: China as a country met Millennium Development Goals regarding maternal mortality rate (MMR) and under 5 mortality rate (U5MR), but high MMR and U5MR persist in various counties, especially rural areas of Western China with predominantly ethnic-minority populations. This study aims to understand multiple factors impacting MMR and U5MR in Xide and Mianning counties in Liangshan Area of Sichuan Province with majority Yi ethnic minority population, as well as the experiences of healthcare providers and mothers in these counties. Methods: Quantitative birth and mortality data from 2012 to 2014 were derived from public and hospital databases. Qualitative methods were used to identify factors which impact MMR and U5MR. We administered structured close-ended surveys to 60 mothers with neonates and 60 healthcare providers and administrators and conducted semi-structured interviews with 26 recently-pregnant mothers regarding their delivery and peri-natal care experiences and with 23 healthcare providers regarding health behaviors and factors driving health disparities. Results: MMR in Xide (72.02 per 100,000) and Mianning (68.10) county are significantly higher than the average MMR for the overall Liangshan Area (43.41), Sichuan (24.40) or the national average (21.8). U5MR in Xide County (12.7%) is consistently higher than in Mianning (7.29%). Of 22 cases of maternal deaths occurring between 2012 and 2014, a disproportionate number (59.9%) were non-hospital births, and 81.81% of those deaths were of Yi ethnic minority women. 73% of medical providers have less than a Bachelor degree and only 40.74% (Xide) or 68.52% (Mianning) scored >80% on evaluations of obstetric and perinatal knowledge and skill. Only 57% of mothers were advised to take folic acid. Mothers who participated in prenatal care programs were more likely to have hospital deliveries (p=0.033) and participate in post-natal care (p=0.05). Significant barriers to care exist due to limited of resources, transportation, cost, health literacy, and cultural norms. Conclusions: MMR and U5MR are higher in Xide and Mianning County and Yi women are disproportionately likely to die in childbirth. Policy changes are necessary to address these inequities, to increase access to quality medical care and improve knowledge and skill-based training for existing medical personnel.