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BACKGROUND: In China, the New Co-operative Medical System (NCMS), a rural health insurance system, has expanded nationwide since 2003. This study aims to describe prenatal care use, content and costs of care in one county where prenatal care is included in the NCMS and two counties where it is not. It also explores the perceptions of stakeholders of the prenatal care benefit package in order to understand the strengths and weaknesses of the approach in the context of rural China and to draw lessons from early implementation.\ud \ud METHODS: This study is based on the data from a cross-sectional survey and a qualitative investigation conducted in 2009. A survey recruited women giving birth in 2008, including 544 women in RC County (which covered prenatal care) and 619, and 1071 in other two counties (which did not). The qualitative investigation in RC included focus group discussions with women giving birth before or after 2007, individual interviews with local policy makers and health managers, NCMS managers and obstetric doctors in township hospitals.\ud \ud RESULTS: There were no significant differences in prenatal care use between RC County (which covered prenatal care) and other two counties (which did not): over 70% of women started prenatal visits early and over 60% had five or more visits. In the three counties: a small proportion of women received the number of haemoglobin and urine tests recommended by the national guideline; 90% of women received more ultrasound tests than recommended; and the out-of-pocket expenditure for prenatal care consumed a high proportion of women's annual income in the low income group. In RC: only 20% of NCMS members claimed the reimbursement; the qualitative study found that the reimbursement for prenatal care was not well understood by women and had little influence on women's decisions to make prenatal visits; and several women indicated that doctors suggested them taking more expensive tests.\ud \ud CONCLUSIONS: Whether or not prenatal care was included in the NCMS, prenatal care use was high, but the contents of care were not provided following the national guideline and more expensive tests were recommended by doctors. Costs were substantial for the poor.

METHODS: Data from cross-sectional household-based health surveys carried out in ten western rural provinces of China in 2003 and 2008 were used in the study. The study population comprised women giving birth in 2002 or 2007, with 917 and 809 births, respectively. Correlations between outcomes and explanatory variables were studied by logistic regression models and a log-linear model.\ud \ud RESULTS: Between 2002 and 2007, having no any pre-natal visit decreased from 25% to 12% (difference 13%, 95% CI 10-17%); facility-based delivery increased from 45% to 80% (difference 35%, 95% CI 29-37%); and differences in using pre-natal and delivery care between the income groups narrowed. In a logistic regression analysis, women with lower education, from minority groups, or high parity were less likely to use pre-natal and delivery care in 2007. The expenditure for facility-based delivery increased over the period, but the out-of-pocket expenditure for delivery as a percentage of the annual household income decreased. In 2007, it was 14% in the low-income group. NCMS participation was found positively correlated with lower out-of-pocket expenditure for facility-based delivery (coefficient -1.14 P < 0.05) in 2007.\ud \ud CONCLUSIONS: Facility-based delivery greatly increased between 2002 and 2007, coinciding with the introduction of the NCMS. The rural poor were still facing substantial payment for facility-based delivery, although NCMS participation reduced the out-of-pocket expenditure on average.

Objective: China, like other transitional countries, is encountering socioeconomic-related inequality in maternal and child health. The principal aim of this study was to investigate the utilisation, contents, and costs of maternity care and its related financial burden on households in rural China, particularly in relation to a rural health insurance established in 2003. Materials and methods: This study was conducted in the context of the project Structural hinders to, and promoters of, good maternal care in rural China-CHIMACA . Data were obtained from the National Household Health Services surveys and its additional western surveys in ten western provinces in 2003 and 2008, and a population-based survey on women giving birth in 2008-2009 in five rural counties in three central and western provinces, and qualitative interviews in one of the five study counties. Logistic and linear regressions were used to study factors associated with the use of maternity care and out-of-pocket expenditure. Results: Between 2002 and 2007, the use of maternity care increased, particularly facility-based delivery rising from 45% to 80% in less developed western rural China; the difference in the use of maternity care between income groups became smaller. In 2002-2007, the out-of-pocket expenditure on facility-based delivery increased too, which was 13% of annual household income for the low-income household in 2007. The health insurance was associated with reduced out-of-pocket expenditure for caesarean section (CS), but not for vaginal delivery. The contents of prenatal care were studied in three of the five study counties. In all three counties, the proportions of women having the number of hemoglobin and urine tests recommended by the national guidelines were low, but 90% of women received two or more ultrasound examinations. The qualitative interviews were conducted in one county, which included prenatal care in the health insurance. Several women reported that doctors suggested them to take expensive examinations. In the five rural counties studied, 46% of all births were by CS with 13% occurring as an (self-reported) emergency CS and 33% of a non-emergency CS. Women reported that half of the non-emergency CSs were recommended by a doctor and half were requested by themselves. The health insurance was associated with having CS, in particular having non-emergency CS. Conclusion: Coinciding with the rural health insurance development, the use of maternity care in rural China has greatly improved. Nevertheless, more expensive examinations or procedures were often recommended by doctors. The financial burden relating to the use of maternity care for the rural poor remained high. The current health insurance lacks the tools required to control costs and to encourage good quality of care. Tausta: Kiinassa sosioekonomiset erot äitien ja lasten terveydessä ovat suuret. Suuri este äitiysterveyden parantamisessa on laadukkaiden äitiyshuoltopalveluiden puuttuminen maaseudun naisilta. Vuonna 2003 maaseudun sairausvakuutus laajentui valtakunnalliseksi. Siihen kuuluu äitiyshuollon etuuspaketti, joka kattaa sairaalasynnytykset. Muutamissa lääneissä järjestelmään kuuluu myös raskaudenaikainen hoito. Tavoitteet: Tämän tutkimuksen tavoitteena oli selvittää äitiyshuoltopalveluiden käyttöä, sisältöä ja kustannuksia Kiinan maaseudulla, erityisesti suhteessa sairausvakuutukseen. Aineisto: Tutkimuksessa käytettiin useita tietolähteitä: 1) kansallisia haastattelututkimuksia vuosilta ja 2) erityiskyselyjä Länsi-Kiinassa vuosina 2002 ja 2007 synnyttäneille maaseudun naisille, 3) väestöpohjaista kyselytutkimusta vuosina 2008 2009 synnyttäneille naisille kolmessa läänissä ja 4) laadullista haastatteluaineistoa. Tulokset: Vuosien 2002 ja 2007 välillä Länsi-Kiinan vähän kehittyneellä maaseudulla raskaudenaikaisia palveluja käyttämättömien naisten määrä laski 25 %:sta 12 %:iin ja sairaalasynnytysten osuus kasvoi 45 %:sta 80 %:iin. Erot eri tuloryhmien välillä kapenivat. Vuosien 2002 2007 aikana laitossynnytysten kustannukset maaseudun kotitalouksille lähes kaksinkertaistuivat. Kolmessa tutkimusläänissä riippumatta siitä, sisältyikö raskausajan hoito sairausvakuutukseen vai ei, yli 70 % naisista kävi neuvolassa kahdentoista raskausviikon kuluessa ja yli 60 %:lla naisista oli vähintään viisi käyntiä. Naisten kustannukset (osuus tuloista) olivat paljon suuremmat pienituloisilla kuin muilla naisilla. Korvauksella oli vain vähän vaikutusta naisten päätöksiin käyttää äitiyshuollon palveluja raskausaikana. Raskauden aikaisten käyntien sisältö vaihteli. Suositusten mukaisten veri- ja virtsatutkimusten määrä oli vähäinen, mutta 90%:lle naisista oli tehty kaksi tai useampi ultraäänitutkimus. Kalliit tutkimukset ja hoitotoimet olivat usein lääkäreiden suosittelemia. Lähes puolet (46 %) kaikista lapsista syntyi keisarileikkauksen avulla. Puolet suunnitelluista keisarileikkauksista oli lääkärien suosittelemia ja puolet naisten itsensä pyytämiä. Lääneissä, joissa keisarileikkausten määrä oli keskitasoa (28 % - 63 %), vakuutus oli yhteydessä lisääntyneeseen keisarileikkausten määrään, etenkin suunniteltujen keisarileikkausten määrään. Päätelmät: Kiinan maaseudulla äitiyshuoltopalveluiden käyttö lisääntyi huomattavasti vuosien 2002 ja 2007 välillä. Kansallisia ohjeita hoidon sisällössä ei noudatettu. Äitiyshuoltoon ja synnytykseen liittyvä taloudellinen taakka maaseudun köyhien keskuudessa pysyi korkeana. Nykyisessä vakuutusjärjestelmässä ei ole välineitä, joilla voidaan hallita kustannuksia ja edistää laadukasta hoitoa.