我国孕产妇与儿童卫生干预措施覆盖率的现状及公平性研究
发布时间：2018-08-28 18:30
【摘要】：一、研究背景 近二十年来,我国孕产妇和儿童的生存状况有了明显的改善,己基本达到了联合国制定的千年发展目标4和5。然而孕产妇与儿童的生存与健康仍面临着两个巨大的挑战。一是既往我国的妇幼卫生体系中缺乏整合和连续性,使妇幼卫生服务的成本——效益没有得到最大化。二是孕产妇和儿童生存整体的改善掩盖了地区和人群间的差异。既往研究已经明确整合若干孕产妇和儿童卫生干预措施可以有效降低孕产妇和儿童死亡。而要连续、有效地改善孕产妇和儿童生存与健康,弥合不同地区和人群之间的差异,就需要综合反映保健连续性的孕产妇和儿童卫生干预措施覆盖率指标,并对干预措施覆盖率在不同地区和不同人群的差异进行分析,既有利于卫生服务资源的合理导向与配置,又可以明确需要重点干预的人群并制定相应的干预策略。 近年来国内外对于妇幼卫生健康公平性的研究热度递增。在发展中国家的研究中发现社会经济状况好的家庭孕产妇和儿童卫生干预措施覆盖率普遍优于社会经济状况差的家庭,城市地区、受教育程度高、和非少数民族的妇幼卫生服务利用程度更好。我国的研究也有类似的发现,在农村地区、贫困家庭孕产妇保健的利用程度较差。 然而现有的文献中均在以下几点局限性：1)尚没有体现保健连续性的孕产妇和儿童干预措施指标体系。2)孕产妇产前保健和产后保健的公平性研究结论不一致,有待于进一步验证和分析。且尚未发现针对儿童卫生服务(如免疫接种、常见病管理)公平性的研究。3)个体水平卫生服务公平性的研究和对公平性影响因素进行探索的研究甚少。 因此本研究通过选择综合评价孕产妇和儿童卫生干预措施覆盖率的指标,并应用不公平的测度方法描述我国地区和个体(不同家庭社会经济状况)两个层面孕产妇和儿童卫生干预措施的现状和不公平程度,并探讨其影响因素。 二、研究方法 本研究数据来源于2008年开展的第四次国家卫生服务调查的家庭健康询问调查部分,共计调查了全国31个省、自治区、直辖市共56456户家庭。由经过培训的卫生工作者使用结构式问卷进行询问。本研究中仅采用家庭健康询问调查部分的家庭一般情况、家庭成员健康询问调查、15-49岁已婚育龄妇女情况和5岁以下儿童情况四个部分的数据。分析产前、产时和产后孕产妇干预措施以及早开奶时,分析的样本量为7414名母亲——儿童对。而在分析儿童喂养(除早开奶外)、免疫接种和儿童腹泻时,总分析的样本量为9639名5岁以下儿童。 通过回顾目前国际上通用的孕产妇和儿童卫生干预措施覆盖率指标体系和国内的指标体系,最终选择了11项孕产妇和儿童卫生干预措施覆盖率作为分析的核心指标。通过加权计算描述我国孕产妇和儿童卫生干预措施覆盖率的现状和地区差异、采用绝对差值和相对比值来定量分析地区差异的大小,并辅以地理分布图来直观呈现各省的分布。以家庭人均年生活消费性支出作为划分人群社会经济状况的依据,并采用健康不公平绝对和相对指标(集中指数)来测度孕产妇和儿童卫生干预措施的覆盖率的公平性,通过(Q1-Q2)/(Q5-Q4)和图示计算不公平的类型。 三、研究结果 (一)孕产妇与儿童卫生干预措施覆盖率的现状 至少进行一次产前保健和住院分娩的覆盖率最高,分别为94.65%和89.55%。儿童期辅食添加、免疫接种和腹泻的口服补液治疗的覆盖率分别为72.45%、80.38%和73.96%。至少进行1次产后访视的覆盖率为53.94%。产前保健的质量指标的两项指标(满足产前检查基本质量和产前保健至少5次且满足产前检查基本质量)的覆盖率为62.01%和39.08%。早开奶和纯母乳喂养6个月的比例均低于40%。 (二)孕产妇与儿童卫生干预措施覆盖率的地区差异 通过地区和分省分析,孕产妇和儿童卫生干预措施最低的仍然多集中在西部省份,如云南、青海、贵州、新疆、西藏等省份。尽管大多数孕产妇和儿童卫生干预措施在城乡之间未见显著的差别,然而Ⅳ类农村地区产前保健和住院分娩最低。此外,与至少进行过一次产前保健的高覆盖率(95%)相比,至少进行过4次或5次产前保健以及满足产前检查基本质量的比例则仅为66%、52%和62%,而产前保健至少5次且满足产前保健基本质量的比例更低(39.08%)。 (三)孕产妇与儿童卫生干预措施覆盖率的公平性 无论其整体覆盖率的高低,产前、产时和产后保健的集中指数均大于0,提示存在着随家庭社会经济状况升高而覆盖率增加的趋势,即亲富人(pro-rich)现象,且不同指标之间的不公平程度也存在差异。最富裕与最贫困人群产前保健至少5次且满足产前检查基本质量覆盖率的绝对差值达到了57%,最富裕人群的覆盖率是最贫困人群的3.94倍。住院分娩在最贫困与最富裕人群覆盖率的差距较小(差值为12%,比值为1.15)。产后访视整体的覆盖率低,而最富裕与最贫困人群之间的覆盖率也存在着差距(差值为25%,比值为1.58)。婴幼儿喂养中仅发现纯母乳喂养6个月存在不公平的现象(集中指数=-0.93,P0.0001),其覆盖率随着家庭社会经济状况的上升而下降,即“亲穷人”。对于免疫接种和儿童腹泻的管理,本研究没有发现显著的不公平现象。 对于不公平类型的分析发现,整体覆盖率高(≥90%)的干预措施(如至少进行一次产前保健、住院分娩),其不公平的类型为bottom型,提示家庭社会经济状况最差的20%的人群干预措施的覆盖率明显落后于其他等级。而覆盖率低(39%-70%)的干预措施(如至少进行过5次产前保健、孕早期进行产前保健、有质量的产前保健、至少进行过4次产前保健且有质量的产前保健以及至少进行过5次产前保健且有质量的产前保健),其不公平的类型为top型,即家庭社会经济状况最好的20%的人群干预措施的覆盖率明显优于其他等级。 (四)不公平的影响因素 家庭人均年生活消费性支出在产前保健和产后保健不公平中所占比重最大(47.05%-118.8%)。反映产前保健质量的有效覆盖率指标中,母亲职业和东中西部地区对不公平的贡献率则分别为0.1845-0.2029和0.1212-0.1264。至少进行一次产后保健“亲富人”贡献大的影响因素也包括东中西部地区(贡献率为0.1540)和母亲职业(贡献率为0.1474)。住院分娩不公平的影响因素分别是母亲教育程度(贡献率为0.3690)、家庭人均年生活消费性支出(贡献率为0.2401)和母亲产次(贡献率为0.1768)。 四、结论 我国孕产妇和儿童卫生服务存在发展不平衡。产前、产时保健和儿童期的免疫接种均已达到了较高的覆盖率,然而产后保健、婴幼儿喂养的覆盖率则较低。孕产妇和儿童保健干预措施最低的仍然多集中在西部省份和Ⅳ类农村地区,提示西部和偏远落后的农村地区仍然是没有得到孕产妇和儿童卫生干预措施的有效覆盖,是未来妇幼卫生工作的重点。此外,尽管产前保健的粗干预措施覆盖率高,但是产前保健质量较差且地区差异大。可见即使医疗卫生服务达到了较高的利用,如不加强医疗卫生机构的服务质量、提高卫生工作者的技能和服务水平,孕产妇和儿童卫生干预措施仍未全面惠及目标人群,有效改善孕产妇和儿童的生存与健康。无论整体覆盖率的高低,产前、产时和产后保健均存在着随家庭社会经济状况升高而覆盖率增加的趋势,即亲富人(pro-rich)现象。但干预措施的不公平类型不尽相同。不公平类型的研究也有助于了解干预措施实施过程不公平产生的规律与趋势,从而采取不同的策略尽量弥合不公平。 家庭人均年生活消费性支出在产前和产后保健不公平中所占比重最大,说明影响产前和产后保健不公平的主要因素是家庭对于孕期和产后相关医疗卫生保健服务的购买力。反映产前保健质量的有效覆盖率指标中,母亲职业和东中西部地区对不公平的贡献,说明母亲职业和中西部地区对孕期相关医疗卫生服务利用的不公平也有一定的影响。消除健康不公平既可以采用重点人群的直接干预,也可以实施惠及全体居民的全面覆盖策略。无论何种策略的实施,都需要建立妇幼卫生公平性的监测和评估系统,对孕产妇和儿童卫生干预措施的公平性及影响因素进行持续的监测,明确重点人群并建立追踪机制,为促进卫生服务的公平利用提供理论依据和证据支持。
[Abstract]:First, the research background.
In the past 20 years, the living conditions of pregnant women and children in China have improved significantly, and have basically reached the Millennium Development Goals 4 and 5 set by the United Nations. However, the survival and health of pregnant women and children are still facing two great challenges. First, the lack of integration and continuity in China's maternal and child health system has made maternal and child health clothing. The cost-effectiveness of services is not maximized. Second, the overall improvement in maternal and child survival masks regional and population differences. Previous studies have clearly integrated a number of maternal and child health interventions that can effectively reduce maternal and child mortality. Health, bridging the differences between different regions and populations, we need to comprehensively reflect the continuity of maternal and child health care interventions coverage indicators, and the coverage of interventions in different regions and different groups of differences in analysis, not only conducive to the rational direction and allocation of health services resources, but also can be clear about the need for heavy Point out intervening crowd and formulate corresponding intervention strategy.
In recent years, there has been an increasing research interest in the equity of maternal and child health both at home and abroad. In developing countries, studies have found that the coverage of maternal and child health interventions in families with good socio-economic conditions is generally better than that in families with poor socio-economic conditions, urban areas, highly educated, and maternal and child health services in non-ethnic minorities. The utilization of maternal health care in poor families is poor in rural areas.
However, the existing literature has the following limitations: 1) There is no indicator system of maternal and child intervention measures reflecting the continuity of health care. 2) The conclusion of the study on the equity of prenatal and postnatal health care is inconsistent and needs further validation and analysis. Research on fairness of health services at individual level and factors affecting fairness are few.
In this study, the coverage rate of maternal and child health interventions was evaluated by selecting indicators and unfair measures were used to describe the status quo and unfairness of maternal and child health interventions at different levels in China.
Two, research methods.
The data of this study were collected from 56 456 households in 31 provinces, autonomous regions and municipalities directly under the Central Government in 2008. The trained health workers used structured questionnaires to ask questions. Data were collected from 4,414 mothers and children aged 15-49 and under 5 years. The sample size was 7,414 mothers and children for prenatal, intrapartum and postpartum interventions and early breast-feeding. For children with diarrhea, the total sample size was 9639 children under 5 years of age.
By reviewing the current international and domestic indicators of maternal and child health interventions coverage, 11 maternal and child health interventions coverage rates were selected as the core indicators for analysis. The absolute difference and relative ratio were used to quantitatively analyze the regional differences, and the geographical distribution map was used to visually show the distribution of the provinces. The per capita annual living expenditure was used as the basis for dividing the social and economic conditions of the population, and the absolute and relative indexes of health inequality (concentration index) were used to measure the pregnant and lying-in women. Equity in coverage of maternal and child health interventions was calculated by (Q1-Q2) / (Q5-Q4) and charts.
Three, research findings
(1) the current situation of maternal and child health intervention measures
The coverage rates of at least one prenatal care and hospital delivery were 94.65% and 89.55%, respectively. The coverage rates of supplementary food, immunization and oral rehydration for diarrhea in childhood were 72.45%, 80.38% and 73.96%, respectively. The coverage rates of at least one postnatal visit were 53.94%. The coverage rates of basic quality of antenatal examination and antenatal care at least 5 times and meeting the basic quality of antenatal examination were 62.01% and 39.08%, respectively.
(two) regional differences in maternal and child health interventions coverage
By regional and provincial analysis, the lowest level of maternal and child health interventions is still concentrated in Western provinces, such as Yunnan, Qinghai, Guizhou, Xinjiang and Tibet. In addition, compared with the high coverage rate (95%) with at least one antenatal care, only 66%, 52% and 62% had at least four or five antenatal care and met the basic quality of antenatal care, while the proportion with at least five antenatal care and met the basic quality of antenatal care was lower (39.08%).
(three) fairness of maternal and child health interventions coverage
Regardless of the overall coverage, the prenatal, intrapartum and postpartum health care concentration index is greater than 0, suggesting that there is a trend of increasing coverage with the increase of family socio-economic conditions, that is, pro-rich phenomenon, and the degree of inequity between different indicators also varies. The richest and poorest groups have at least five prenatal care. The absolute difference between the coverage of basic quality of antenatal care reached 57%, and the coverage of the richest was 3.94 times that of the poorest. There was also a gap in coverage rate (25% difference, 1.58 ratio). Only 6 months of exclusive breastfeeding was found to be unfair (concentration index = - 0.93, P 0.0001), and the coverage rate declined with the rise of family socio-economic conditions, i.e.'pro-poor'. Significant inequalities.
An analysis of unfair types found that interventions with high overall coverage (> 90%) such as at least one antenatal care, hospital delivery, and the unfair type was bottom, suggesting that the coverage of interventions in the 20% of the population with the worst socio-economic status in the family lagged significantly behind other levels, while interventions with low coverage (> 39% - 70%). Measures (e.g. at least five prenatal care, early prenatal care, quality prenatal care, at least four prenatal care and quality prenatal care, and at least five prenatal care and quality prenatal care) are of the top type, i.e. 20% of the population with the best socio-economic status in the family. The coverage of intervention measures is obviously better than that of other grades.
(four) factors affecting inequity
Per capita annual expenditure on household living accounts for the largest proportion of unfair prenatal and postnatal care (47.05% - 118.8%). The influencing factors of the "rich" contribution included the east, middle and west regions (contribution rate 0.1540) and the mother's occupation (contribution rate 0.1474). The unfair factors of in-hospital delivery were maternal education level (contribution rate 0.3690), family per capita annual consumption expenditure (contribution rate 0.2401) and maternal parity (contribution rate 0.1768).
Four. Conclusion
Prenatal health care and childhood immunization coverage have reached a high level, but postnatal health care and infant feeding coverage are low. The lowest maternal and child health interventions are still concentrated in western provinces and rural areas of type IV, suggesting that Western and remote rural areas are still not effectively covered by maternal and child health interventions, which is the focus of future maternal and child health work. In addition, although the coverage rate of crude interventions in antenatal care is high, the quality of antenatal care is poor and the regional differences are great. It can be seen that even if medical and health services have reached a high level. Utilization, such as not strengthening the service quality of medical and health institutions, improving the skills and service level of health workers, maternal and child health interventions have not yet fully benefited the target population, effectively improving the survival and health of pregnant women and children. Pro-rich phenomena will increase with the increase of economic conditions, but the unfair types of intervention are not the same. The study of unfair types will also help to understand the law and trend of unfairness in the implementation process of interventions, so as to adopt different strategies to bridge the unfairness as far as possible.
The annual per capita living expenditure of the family accounts for the largest proportion of prenatal and postnatal health care inequities, indicating that the main factor affecting prenatal and postnatal health care inequities is the family's purchasing power for prenatal and postnatal related health care services. The contribution of ministries and regions to unfairness shows that the mother's occupation and the middle and western regions also have a certain impact on the unfairness of medical and health service utilization during pregnancy. Establish the monitoring and evaluation system of maternal and child health equity, continuously monitor the equity of maternal and child health interventions and influencing factors, identify key groups and establish a tracking mechanism to provide theoretical basis and evidence support for promoting the fair use of health services.
【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2013
【分类号】：R172
本文编号：2210237
[Abstract]:First, the research background.
In the past 20 years, the living conditions of pregnant women and children in China have improved significantly, and have basically reached the Millennium Development Goals 4 and 5 set by the United Nations. However, the survival and health of pregnant women and children are still facing two great challenges. First, the lack of integration and continuity in China's maternal and child health system has made maternal and child health clothing. The cost-effectiveness of services is not maximized. Second, the overall improvement in maternal and child survival masks regional and population differences. Previous studies have clearly integrated a number of maternal and child health interventions that can effectively reduce maternal and child mortality. Health, bridging the differences between different regions and populations, we need to comprehensively reflect the continuity of maternal and child health care interventions coverage indicators, and the coverage of interventions in different regions and different groups of differences in analysis, not only conducive to the rational direction and allocation of health services resources, but also can be clear about the need for heavy Point out intervening crowd and formulate corresponding intervention strategy.
In recent years, there has been an increasing research interest in the equity of maternal and child health both at home and abroad. In developing countries, studies have found that the coverage of maternal and child health interventions in families with good socio-economic conditions is generally better than that in families with poor socio-economic conditions, urban areas, highly educated, and maternal and child health services in non-ethnic minorities. The utilization of maternal health care in poor families is poor in rural areas.
However, the existing literature has the following limitations: 1) There is no indicator system of maternal and child intervention measures reflecting the continuity of health care. 2) The conclusion of the study on the equity of prenatal and postnatal health care is inconsistent and needs further validation and analysis. Research on fairness of health services at individual level and factors affecting fairness are few.
In this study, the coverage rate of maternal and child health interventions was evaluated by selecting indicators and unfair measures were used to describe the status quo and unfairness of maternal and child health interventions at different levels in China.
Two, research methods.
The data of this study were collected from 56 456 households in 31 provinces, autonomous regions and municipalities directly under the Central Government in 2008. The trained health workers used structured questionnaires to ask questions. Data were collected from 4,414 mothers and children aged 15-49 and under 5 years. The sample size was 7,414 mothers and children for prenatal, intrapartum and postpartum interventions and early breast-feeding. For children with diarrhea, the total sample size was 9639 children under 5 years of age.
By reviewing the current international and domestic indicators of maternal and child health interventions coverage, 11 maternal and child health interventions coverage rates were selected as the core indicators for analysis. The absolute difference and relative ratio were used to quantitatively analyze the regional differences, and the geographical distribution map was used to visually show the distribution of the provinces. The per capita annual living expenditure was used as the basis for dividing the social and economic conditions of the population, and the absolute and relative indexes of health inequality (concentration index) were used to measure the pregnant and lying-in women. Equity in coverage of maternal and child health interventions was calculated by (Q1-Q2) / (Q5-Q4) and charts.
Three, research findings
(1) the current situation of maternal and child health intervention measures
The coverage rates of at least one prenatal care and hospital delivery were 94.65% and 89.55%, respectively. The coverage rates of supplementary food, immunization and oral rehydration for diarrhea in childhood were 72.45%, 80.38% and 73.96%, respectively. The coverage rates of at least one postnatal visit were 53.94%. The coverage rates of basic quality of antenatal examination and antenatal care at least 5 times and meeting the basic quality of antenatal examination were 62.01% and 39.08%, respectively.
(two) regional differences in maternal and child health interventions coverage
By regional and provincial analysis, the lowest level of maternal and child health interventions is still concentrated in Western provinces, such as Yunnan, Qinghai, Guizhou, Xinjiang and Tibet. In addition, compared with the high coverage rate (95%) with at least one antenatal care, only 66%, 52% and 62% had at least four or five antenatal care and met the basic quality of antenatal care, while the proportion with at least five antenatal care and met the basic quality of antenatal care was lower (39.08%).
(three) fairness of maternal and child health interventions coverage
Regardless of the overall coverage, the prenatal, intrapartum and postpartum health care concentration index is greater than 0, suggesting that there is a trend of increasing coverage with the increase of family socio-economic conditions, that is, pro-rich phenomenon, and the degree of inequity between different indicators also varies. The richest and poorest groups have at least five prenatal care. The absolute difference between the coverage of basic quality of antenatal care reached 57%, and the coverage of the richest was 3.94 times that of the poorest. There was also a gap in coverage rate (25% difference, 1.58 ratio). Only 6 months of exclusive breastfeeding was found to be unfair (concentration index = - 0.93, P 0.0001), and the coverage rate declined with the rise of family socio-economic conditions, i.e.'pro-poor'. Significant inequalities.
An analysis of unfair types found that interventions with high overall coverage (> 90%) such as at least one antenatal care, hospital delivery, and the unfair type was bottom, suggesting that the coverage of interventions in the 20% of the population with the worst socio-economic status in the family lagged significantly behind other levels, while interventions with low coverage (> 39% - 70%). Measures (e.g. at least five prenatal care, early prenatal care, quality prenatal care, at least four prenatal care and quality prenatal care, and at least five prenatal care and quality prenatal care) are of the top type, i.e. 20% of the population with the best socio-economic status in the family. The coverage of intervention measures is obviously better than that of other grades.
(four) factors affecting inequity
Per capita annual expenditure on household living accounts for the largest proportion of unfair prenatal and postnatal care (47.05% - 118.8%). The influencing factors of the "rich" contribution included the east, middle and west regions (contribution rate 0.1540) and the mother's occupation (contribution rate 0.1474). The unfair factors of in-hospital delivery were maternal education level (contribution rate 0.3690), family per capita annual consumption expenditure (contribution rate 0.2401) and maternal parity (contribution rate 0.1768).
Four. Conclusion
Prenatal health care and childhood immunization coverage have reached a high level, but postnatal health care and infant feeding coverage are low. The lowest maternal and child health interventions are still concentrated in western provinces and rural areas of type IV, suggesting that Western and remote rural areas are still not effectively covered by maternal and child health interventions, which is the focus of future maternal and child health work. In addition, although the coverage rate of crude interventions in antenatal care is high, the quality of antenatal care is poor and the regional differences are great. It can be seen that even if medical and health services have reached a high level. Utilization, such as not strengthening the service quality of medical and health institutions, improving the skills and service level of health workers, maternal and child health interventions have not yet fully benefited the target population, effectively improving the survival and health of pregnant women and children. Pro-rich phenomena will increase with the increase of economic conditions, but the unfair types of intervention are not the same. The study of unfair types will also help to understand the law and trend of unfairness in the implementation process of interventions, so as to adopt different strategies to bridge the unfairness as far as possible.
The annual per capita living expenditure of the family accounts for the largest proportion of prenatal and postnatal health care inequities, indicating that the main factor affecting prenatal and postnatal health care inequities is the family's purchasing power for prenatal and postnatal related health care services. The contribution of ministries and regions to unfairness shows that the mother's occupation and the middle and western regions also have a certain impact on the unfairness of medical and health service utilization during pregnancy. Establish the monitoring and evaluation system of maternal and child health equity, continuously monitor the equity of maternal and child health interventions and influencing factors, identify key groups and establish a tracking mechanism to provide theoretical basis and evidence support for promoting the fair use of health services.
【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2013
【分类号】：R172
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