China Countdown Case Study

China Countdown Case Study (2014-2015)


China’s success in maternal and newborn health (MNH) has been unprecedented. Twenty years ago, parts of rural China experienced levels of maternal and neonatal mortality that are similar to those seen in sub-Saharan Africa today. Today, the neonatal mortality rate in rural areas is 9 per 1000 live births, and maternal mortality is 26 per 100,000 live births, with provincial ratios ranging from 2 to 176 maternal deaths per 100,000 live births. The reasons for this success are multiple, but China’s strategic investments in health systems strengthening – including strengthening infrastructure and staff training and supervision in township and lower-level hospitals; reinforcing channels for referral to tertiary hospitals equipped to deal with emergency obstetric care; and providing subsidies to women and/or hospitals to encourage hospital delivery – has been critical. Today, nearly all women give birth in hospital.

Project Aims

The aim of this case study is to document and understand trends and socio-economic and geographic inequalities in maternal and newborn mortality and fertility in China over the last twenty years. The focus of this work will be on system inputs and outputs that have enabled progress towards universal access to basic and comprehensive obstetric care in health facilities, particularly for the rural poor and those living in remote areas, and the financing mechanisms that facilitated removal of financial barriers at the point of care.


Equity analyses, with a particular focus on Western China, will be critical. We will focus on delivering results for the poorest groups through the analysis of relevant data at national and sub-national levels that can be disaggregated by socio-economic groups and used to highlight disparities and actions required. Our analysis will focus on evidence from Western China where progress has been more recent and the socio-economic context may have more relevance for sub-Saharan Africa.

This case study will rely on the analysis of existing data, including (but not limited to):

  1. A document review of all policies relevant to MNH and fertility decline over the last twenty years (including the most recent health reforms);
  2. A review of the published literature on MNH and fertility changes in China;
  3. An analysis of time trends, causes and regional differences in maternal and newborn mortality, fertility and use of MNH services in China between 1996 and 2012;
  4. An analysis of possible adverse consequences of some MNH and fertility policies, including excessive caesarean sections and antenatal ultrasound scans and an increased sex ratio at birth;
  5. An analysis of the role of China’s facility-based birth strategy in the reduction of maternal mortality between 1996 and 2012 (as in reference 2 for neonatal mortality);
  6. An analysis of the relationship between health system inputs and outputs, contextual factors and maternal and neonatal mortality across all 3255 counties in China between 1996 and 2012.

Expected Outcomes

The expected outcome of the various analyses will be a rigorous assessment of the evidence of what underpins China’s improvements in MNH and fertility decline, particularly among the poor; with a special focus on lessons that are relevant to sub-Saharan Africa.

The main institutions involved are the Schools of Public Health at Peking University and Sichuan University, and the London School of Hygiene and Tropical Medicine (Professor Carine Ronsmans and Timothy Powell-Jackson, a health economist). At Peking University, the project will be led by Qingyue Meng, Professor in Health Policy and Economics and Director of the School of Public Health (SPH), with co-investigators Yan Wang, Professor in Maternal and Child Health and Xing Lin Feng, Associate Professor in Health Policy. At Sichuan University the project will be led by Min Yang, Professor in Health Systems at the School of Public Health. We will also involve the Director of the Department of Maternal and Child Health at the Ministry of Health; and we have approached Dr. Shi Kun Zhang at the Department of Maternal and Child Health of the National Health and Family Planning Commission of the People’s Republic of China for an interest in this case study.

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