Karolina Koval and Laura Torres, Fudan University, China – special for InfoBRICS
Support for maternal health is essential to address the world's demographic challenge. The social protection of motherhood and childhood is a subject of special attention on the part of the state, as the health and well-being of women and future children is guaranteed by the growth of the healthy population of the country. The state of maternal health has been one of the most important activities of WHO since 1948. The UN is currently an active participant in the protection of motherhood in the international arena. Maternal health is at the top of the Millennium Development Goals.
However, firstly we should determine what prenatal maternal health to research our topic is. Prenatal maternal health is the health of women during pregnancy period. Policy of prenatal maternal health encompasses the health care dimensions of family planning, preconception, prenatal care in order to ensure a positive and fulfilling experience in most cases and reduce maternal morbidity and mortality in other cases. Generally, adequate prenatal care encompasses medical care and educational, social, and nutritional services during pregnancy.
Every day, approximately 830 women die from causes related to pregnancy and childbirth. That is why it is necessary to care about maternal health before giving birth. The main purpose is to reduce the number of deaths of women that occur as a result of pregnancy and childbirth. Increasing access to reproductive services (family planning, contraceptive methods, prenatal and antenatal care) and providing women with the appropriate information and care to promote health to help achieve universal access to reproductive health.
We decided to analyze the policies of maternal health in such countries as Brazil, Russia and China. This is due to several facts. First, women are a socio-demographic group in particular need of social protection in market conditions. Women perform the main social and family function - childbearing. Second, these countries have big territories and a lot of changes for the last time. Third, they have same goals of development due to BRICS cooperation and of course, they are active Parties in United Nations.
The aim of this work is to study the social protection of maternal health in Brazil, Russia and China.
To achieve this goal it is necessary to solve the following tasks:
- describe the different directions of development of social protection of prenatal maternal health.
- to assess the regulatory framework at the present stage.
- to analyze programmes and measures for the social protection of prenatal maternal health.
The maternal health policies progress varied widely across countries, even where levels of income are similar. For example, by contrasting the evolution of this policies in Brazil and China, the later had a relatively higher drop in the Maternal Mortality Ratio (MMR). In order to improve maternal health statistical correlations, show several factors that have to be tackled and changed. Improving certain variables have shown to have a great impact in the main factor used to measure maternal health is the MMR. The MMR measures the number of maternal deaths per 100,000 live births. Whether a policy worked or not, it can be evaluated through the improvement of these variables and ultimately in the reduction of the MMR. It is also suggested that one important variable is financial support, especially for the poor. It leads to a greater access and use of maternal health services. Such a support could be for example reducing user fees or giving free healthcare for women during and shortly after their pregnancy.
Other factors that are commonly known to have to be improved are on various levels and sectors. A good health information system is needed, in order to fathom out problems and conduct research. A high ratio of health workforce per population, coverage of medical products and vaccines, economic development or specifically socio-economic development, poverty reduction, education (for women) and gender empowerment are factors whose improvement have a positive impact on maternal health.. Concerning the individual access to antenatal care during pregnancy, it is important to receive at least four antenatal care visits according to previous WHO and UNICEF recommendations. Current WHO recommendations demand ate least eight antenatal care visits. But each country has their own standards, for instance, China has four visits as its standard, in Brazil they consider ideal seven visits. (what is each country's standard? Is it 4/5??). During childbirth the attendance of skilled care is crucial, like midwives, trained nurses or specialized doctors. Skilled health workers also look out for complications; hemorrhage accounts for 27.1% of worldwide maternal deaths, eclampsia for 14.1% and sepsis for 10.7%.
The WHO (2011) also reported, after assessing policies from many countries, that there was no standard formula and countries employed different approaches, some addressed particularities and other were flexible to changeable conditions. However, after conducting an analysis over the countries that most succeed with their national policies, the WHO (2014) pointed out that the progress in some countries was led due to a multisectoral action, because the determinants to improve maternal health were within and beyond the health sector. Another key aspect when implementing these policies are the use of systematic data reviews and meta-analysis combined by improving the quality of the health interventions that are delivered (WHO, 2014b). In sum, as it is further detailed in by the WHO (2013), the analytical framework to follow up on these policies considers the MMR as dependent variable, and the independent variables range from factors related to investment in the health sector which universal access to services (service delivery, health workforce, information, medical products, financing, health system governance), sectors outside health (infrastructure development, education, environmental conditions, national capacities) and other cross-sectoral enabling factors for health (population dynamics, women's socioeconomic status, levels of inequality, economic development, governance and leadership).
Nevertheless, there are some evaluation shortcomings when evaluating maternal health policies, which include limited measures of enabling factors such as value for money (because it varies from place to place) and the adaptive capacities to implement actions and regulate standards (it is also different for many countries) (WHO, 2014c). Even with limitations, research methods for evaluating these policies can be from a range of strategies, such as quantitative mapping of trends, econometric modelling, and Boolean, qualitative comparative analysis, literature review with narrative evidence synthesis, and country-specific literature and data review. Lastly, considering evaluating and success of these policies, the MEASURE Evaluation (2003) supported from the USAID, highlights that one of the most important factors to follow up on these policies are the completeness of the maternity registered data, as it will be frequently the main resource to extend the evaluation to several key-issues. For instance, MEASURE Evaluation studied MMR, perinatal health information system, availability and use of maternity services, midwifery care, among other issues. In the following topics, this paper will assess the maternal health policies structured by Brazil, China and Russia, and compare the strategies with each other.
Overview of three countries, their political and policy structure
Brazil figures among the biggest Latin American Country in terms of economic growth and development, it is also the biggest one in populational size with an amount of around 210 million habitants. However, the country still struggles to reach the development goals aimed under the UN framework. The country did not reach the goal of having a maternal mortality ratio of no more than 35 deaths per 100 thousand live births, according to the WHO, this number nowadays is of 44 deaths. The maternal health policies from the Brazilian government traces back from its dictatorial state, in 1983, when the Program for women's health was created. It aimed prenatal, childbirth and puerperium care, besides cancer and sexually transmitted diseases, adolescent care, contraception, among other areas. The Brazilian health policy was reviewed again in 1988, with the new Federal Constitution. The Constitution conceptualized collective health in a broader sense, as it was recognized as a citizen right the access to health and health services were defined as social benefits. Moreover, it introduced the goal of a Unified Public Health System, which had as guiding principles: decentralization, universal, integral, and equanimous access, and dependent on social participation.
Following the principles established by the Constitution, the maternal health would get governmental attention again only in 2000, when the National Program for the Humanization of Antenatal - Delivery and Post-Partum Care' was created. This program was seen as the turning point for maternal health interventions. Again, the general health policy of the country was reviewed, in 2010, by the establishment of the health care network, which created one health center in each district, and it was organized in various ways so as to provide interventions and services of varying levels, integrated by logistical and management systems to ensure all-round care. The idea here was to guarantee that all citizens had access to health care, even if their original municipality did not own such resources, this individual would be relocated to a facility that would allow the delivery of the health care service as provided by the Constitutional rights. However, Brazil still faces challenges to reduce social inequalities when delivering health services, as well as to guarantee the provision of services in the most remote regions of the country.
China is in a unique position in the world. In the 1960s and 1970s it was still one of the poorest countries in the world. The vast regional differences and income differences due to the fast-economic development created big inequalities. But China's circumstances also grant it a favorable starting position: China has a strong government that is able to efficiently tackle certain societal issues. From 2002 to 2017 the Chinese government rose its expenditure for health and family planning from 3% to 7% of its total expenditures. China had and still has a low fertility rate due to the one-child-policy that was only abolished recently ranking 182 out of 223 countries worldwide. A low fertility rate generates a low maternal mortality ratio, as women get fewer children. The economic growth led hundreds of millions of Chinese outside poverty, creating a new middle class. These are factors that generally underpin improving health.
The health care system that was created between 1998-2007 and in 2013 covered 95% of the population. This was to a big part an achievement by creating a rural health insurance in 2003. It is a three-tier service network split in three levels: the province level hospitals and the prefecture and county level hospitals provide basic healthcare services and treat emergency cases. Township level health care centers or village clinics are responsible for some public health services and common diseases. This scheme is paralleled within the Mother-Child-Health system. The facilities on the higher levels give guidance and take over severe cases from the lower level facilities. The important actors concerning maternal health in China are National Health and Family Planning Commission under the roof of the State Council managing the National Programme for Women's Development and the central government with its with year plans and programs, like the Healthy China 2030 program.
Russia has undergone significant economic and social changes since the collapse of the Soviet Union. Over the past 20 years, the country has gone from a globally isolated, centrally planned economy to a market-based, globally integrated economic system. Since 1999, the Russian economy has started to recover. However, the demographic situation is not affected. In the period from 1992 to 2010, the natural decline in the population of Russia amounted to 13.1 million people. In this regard, a number of important social programmes in support of demography and health care have been adopted.
Today in Russia there are three levels of government: Federal (Central) and regional authorities (the authorities of constituent entities of the Russian Federation: 21 republics, 6 regions, 49 provinces, 10 Autonomous parts, an Autonomous subjects, cities of Federal significance - Moscow and Saint Petersburg) and local authorities (local self-government bodies of districts, cities, towns, and villages). After the collapse of the USSR, along with the decentralization of power in the country, there was a decentralization of the health care system. The health care system has the same structure as the government: there is a Federal (Central), regional (subjects of the Russian Federation) and local health care.
In accordance with the Constitution of the Russian Federation, the Federal government is responsible for the regulation and protection of human and civil rights and freedoms, coordination of health issues (together with the authorities of the Russian Federation). In addition to the Constitution, the main guidance document is the law "Fundamentals of the legislation of the Russian Federation on the protection of public health", adopted in 1993. According to article 41 of the Constitution, all Russian citizens have the right to free medical care. Including pregnant women.
Thus, citizens of the Russian Federation receive free emergency and medical care in state and municipal medical institutions. Financing of the health care system is carried out mainly through taxes, contributions to the Federal Compulsory health insurance Fund and extra-budgetary payments.
Description of policy in each country
As the new laws were adopted, in the 2000's, the maternal health policy was further improved in 2011. The government, though the Ministry of Health, introduced the Stork Network (RC), with a view of providing care in such a way as to ensure that women have the right to family planning and humane care during pregnancy, childbirth and puerperium and that children have the right to a safe birth and growth and healthy development. Among the RC guidelines are: assessment and classification of risk and vulnerability; broader access to and improvements in the quality of prenatal care; registration of the pregnant woman at a major hospital and safe transport; good practices and safety during labor and delivery; and good quality child healthcare during the first 24 months of life.
The whole network is divided in three moments of the pregnancy and one regarding the provision of the service: I – Prenatal; II – Labor and birth; III – Puerperium and child health care; and, IV – Logistic system: Transportation and regulation. This division was designed to work with the public service costs and benefits distribution. Most of the investment comes from the federal government, but a small fraction is responsibility of State or Municipal level. If the municipality doesn't have the healthcare services needed it must cooperate with another region that owns the service and ensure the provision to the pregnant woman. The maternal health policy progress is measured based on the National Program of Access and Quality Improvement (Indicators are drawn from the national database records) and evaluation is conducted based on the "Stork Network" regulation.
As for social protection guarantees regarding maternal health, the Brazilian policy provides a maternity leave 120 days, which the mother can start 28 days prior to the labor. Besides, the mother cannot be fired while pregnant and also 5 months after giving birth. The mother also has the right of changing the work position if it brings risks to the pregnancy. After giving birth, until the baby completes 6 months, the mother can be dismissed from work daily for 1 hour to breast feed. After the changing policies, the country made it to increase in the number of women's seeking for prenatal care: 1,2 (1995) to 10,95 (2010). However, in terms of reaching equality and decreasing inequality in the provision of health care services remained a challenge to the country. Considering, for example, this same indicator, it suggests issues with regional and socioeconomic disparity, as the north and northeast regions of Brazil (where the poorest population is concentrated) had a level of less than 7 health interventions during prenatal care.
A comprehensive policy framework concerning maternal health was established in China in 1994 (Law on Maternal Health Care). It made sex-selected abortions illegal, focused on service standards through creating the Safe Motherhood Programme, promotes a higher access to information, nutrition and maternal services. The recurring and improving National Programme for Women's Development in 1995, 2000 and 2011. With the programs women's health was declared as one of the priorities and was included in China's national economic and social development plans. One goal is for example to reduce the maternal mortality ratio to less than 20 per 100,000 livebirths. Especially the so-called migrant workers give a lot of space for improvement. Another goal is to reduce rural urban disparities. These goals have been tackled by expanding maternal health care and improving the facilities of maternal health care and their access. A special focus was put on the numbers and the quality of health care workers.
The Health China 2030 plan established by National Health and Family Planning Commission in 2016 set as its goal to have 2.5 physicians or physicians' assistants per thousand population until 2020. 16 provinces have already met that goal. China's health insurance covering 95% of the populations includes maternal health components. Together with China's Safe Motherhood Program which supports facility-based births for poor people and rural population, it led to an increase in institutional deliveries to up to 95%, and nowadays 99.9%. In correlation the maternal mortality ratio declined from around 120 to around 60 per 100,000 livebirths.
One way to better maternal health was the establishment of part-time working Maternal and Child Health Clinicians. These have helped to fill the gap in rural areas, where there are no professional cadres. As the Chinese government is a strong government able to tackle specific issues, it tackled maternal health through specific policies. The government is "financing specific services (safe, facility based deliveries, immunizations, integrated management of childhood diseases, and more recently, Prevention of Mother to Child Transmission), allocating resources (including doctors) for poor and remote areas and creating a structure to coordinate efforts to improve the indicators". Hospital delivery has become a universal standard in China.
After the collapse of the Soviet Union, in a period of acute economic crisis, there is a high level of maternal death and demographic crisis. In this regard, the government has agreed on measures to prevent this situation and has developed programmes and amendments to laws.
According to article 23 of the Federal law of the Russian Federation No. 323 on protection of health of citizens the state provides women during pregnancy, in time and after childbirth, with specialized medical care in institutions of the state or municipal health care system. Pregnant women also have the right to work in conditions that are appropriate to their state of health, cannot be dismissed or are not employed because of their physiological condition. Employers are obliged to provide paid maternity leave to pregnant women (Сonstitution of RF, 2014).
Among the main medical, social and legal acts of protection of motherhood and childhood should be highlighted the law of the Russian Federation "On additional measures for the protection of motherhood and childhood", which provides for the duration of maternity leave in 70 calendar days before childbirth and 70 days after childbirth, and in cases of complicated childbirth — 86 days, at birth 2 children and more — 110 days. A one-time benefit (50% of the minimum wage) was introduced in addition to the maternity benefit. Moreover, the resolution of the Supreme Council of the Russian Federation "On urgent measures to improve the status of women, the family, protection of motherhood and childhood in rural areas" establishes annual leave for women of at least 28 calendar days, guarantees a 36-hour working week, provides for hygienic and socio-legal standards for work in hazardous industries.
The presidential decree "On urgent measures to ensure public health" provides for a set of state measures to protect motherhood and childhood. The main legislative acts on health care, labor, social support, etc. create prerequisites for the strengthening of the health of women and children. Thus, prenatal maternal health is protected by a wide network of different medical Institutions. For example: 1) Antenatal clinic, which is provision of medical and preventive care to women during pregnancy and after childbirth; psych prophylactic preparation of pregnant women for childbirth and newborn care. Provision of medical and diagnostic assistance to women with gynecological diseases; etc. 2) Maternity hospital is health care institutions, the number of births in which is from 500 to 2500 per year, having in its structure the Department (chamber) of intensive care and intensive care for women. 3) Perinatal center is assistance during pregnancy and childbirth to patients at high perinatal and obstetric risk, including for women with diseases of other organs and systems, diseases of the reproductive system, infertility, as well as preterm birth from 22 to 34 weeks of pregnancy, providing all types of obstetrics. The separation of perinatal care has improved maternal health in the regions and rural areas, as well as contributed to the efficiency of staff in this sphere.
Besides, the order of the Ministry of health and social development of the Russian Federation of 2006 "On standards of medical care in normal pregnancy" defines list of medical services and a list of medicines provided to pregnant women free of charge. It provides doctor visit, medical tests and research, manipulations and procedures, vitamin and mineral complexes, additional food and medicine. In the special issuing points for pregnant and lactating women, the following products can be obtained: dry milk mixtures, purees and juices from vegetables or fruits (6-7 liters of juice). In addition to the free provision of necessary assistance, women are socially protected during pregnancy and after childbirth.
If a woman applies to the women's consultation in the early stages of pregnancy (up to 12 weeks) and timely dispensary registration, she can receive a one-time allowance in the amount of the minimum wage (in addition to the maternity allowance). With the passage of mandatory medical examinations of the pregnant woman maintains her average earnings. Of course, these measures are of great help even to those women who have financial difficulties. Thus, the financial situation should not affect maternal health. This is the main goal of the Russian government to prevent maternal mortality.
Comparison across countries
The Brazilian MMR was one of the biggest national health targets in the last decades, the country had a significant decrease since the 1990's. The creation of the women's health programs and the reform in the national health system are seen as the factors that helped to reach such changes (LEAL et al., 2018). The country had, in the period of 1990 to 2015, a reduction of 56% of maternal deaths, and according to the Ministry of Health, when analyzing the national health information system these numbers keep falling when comparing the evolution year by year. Besides, for the death records, among the poorest women their death had relations not with issues before the birth, but due to complications after it and, for some cases, it also had connections with clandestine abortions. For women from higher socioeconomic status, the majority of the death records had to do with internal bleeding due to high rates of unnecessary caesarean births. The country also has a rate of 92% of maternal deaths are considered to be able to be preventable.
As for China, declaring hospital delivery to a universal standard has made it possible to reduce the reasons for maternal mortality over the last two decades. Over 75% of maternal deaths are considered to be able to be preventable. By introducing hospital delivery as a universal standard (the overall hospital delivery rate was increased to 99.9%), direct obstetric causes decreased from 71.3 % of the mortality ratio in 2000 to 53.9% in 2017. Almost all Eastern and central China in 2016 had 100% births attended by skilled health personnel. The region with the lowest rate was Tibet that was reaching as much as 98%. These factors have reduced the maternal mortality ratio from 88.9 deaths per 100,000 live births in 1990 to 19.6 in 2017. The correlation between the differing of provinces in hospital delivery rate and in maternal mortality ratio leads to the conclusion, that hospital delivery rate is an independent variable for maternal death. The Chinese maternal mortality ratio is quite low compared to the average upper middle income countries, and much lower than those of the world average or BRICS-nations like South Africa and India.
UNICEF and WHO used to recommend a minimum of four antenatal care visits by skilled health personnel. China achieves as much as a coverage of 81% in that area. An increase in those numbers over the last years is due to China's systematic maternal care management demanding five antenatal care visits and due to a strong enforcement of this in rural China, and in the western and central provinces, which lagged behind compared to urban areas or eastern provinces. For Brazil, this coverage is around 98,7%, the major issue is to reach out for the mothers who live in the most remote or poorest regions of the country. But the WHO'S new recommendation is of at least eight antenatal care visits. Here China lags behind: only 33 percent of women giving birth received at least eight antenatal care visits in 2013. A number that clearly has to be improved. A big regional disparity can be seen concerning antenatal care visits. Concerning women having at least one antenatal care visit the percentages by provinces reach up to 98.0-99.9 percent in some eastern provinces, while Tibet is as low as 89.5 percent. A big urban rural divide cannot be seen within at least one visit antenatal care percentages, but in higher antenatal care visits the rural population lags behind. For Brazil, this coverage is around 75%, the main problems for those individuals who did not had the minimum visits were for the reason that many mother's in order to get the service would have to peregrinate to other locations or they were not aware of the provision of the services.
In the case of Russia, it should be noted that the social policy in the sphere of maternal health protection is similar with China and Brazil in many respects: maternity leave, free medical care during pregnancy and childbirth, payment of maternity leave, payment of one-time benefits are provided. However, there are many differences between, namely:
1. The protection of women in Russia is at a higher level, as in Russia any woman has the right to receive benefits, only the amount of this benefit cannot always provide a decent standard of living. In China, however, protection is provided only to women who work, usually in large cities, while the rural population, for the most part, does not receive any guarantees in the event of pregnancy and childbirth.
2. The difference of mentalities - in Russia more attention is paid to the upbringing of the child directly in the family, next to the mother, hence the leave to care for a child up to 1.5 years and from 1.5 to 3 years. Statistics show that most women remain on parental leave until they reach 1.5 years of age. Up to 3 years to stay at home does not allow the economic situation - the allowance is deplorable.
In China, the focus of state policy in General on "work without interruption" and the long existence of the "One family - one child "programme. Hence the "fear of pregnancy" on the part of women and the provision of short leave by the state, although it can be provided to the father, too, as well as the desire of women to quickly go to work, as a long absence affects career growth and bonuses.
3. The result of the reforms should be an increase in the birth rate. The main difference is that in China, the permissible number of children is strictly regulated and now limited to two, and in Russia, the maximum number of children in the family is not regulated, on the contrary, many children are welcome.
According to forecasts, about two million children were to be born in China in 2015. China is ready to increase the birth rate in 2015, across the country purchased new hospital beds and trained midwives, with special attention to issues of childbirth after the peak of fertility.
1 million 947 thousand children were born in Russia in 2014, such a number of births have not been in the history of Russia. For the third year in a row, the birth rate in the country is at 1.9 million, and its total coefficient has increased significantly and is 1.76. One of the factors that continue to influence the increase in the birth rate is the maternity capital. Also, the level of medical care should not be underestimated.
4. The amount of insurance premiums in Russia is higher than in China, but this is due to the fact that in Russia and the unemployed who have registered with the employment service are entitled to payments, while in China payments are made only to employees whose employers paid contributions to the maternity insurance Fund.
5. The main measures that need to be taken for further development: in China it is necessary to develop social insurance in remote areas from big cities (rural areas). Currently, not all the population is covered by these social benefits. In Russia, it is necessary to increase the minimum benefit to the average earnings by region. The current minimum benefit cannot be a real incentive for the birth of a child.
In Brazil, many challenges are still to be faces, for instance the delivery of the services suffer from regional and socioeconomic disparities. Besides, the country still has a high rate of births that are done by the use of caesarian interventions and had a tendency to increase. Besides, the assessment and evaluation of the programs should be carried in a national coverage, for example, in Brazil the assessments were not conducted in all twenty-seven federal states. Still, the country has made great efforts to improve its service structure, and has been conducting national programs to increase its specialized maternal health workforce and changing its regulation to increase the amount of "natural" births.
Generally, one can say even though China has improved a lot over the past decades, a higher government financing should be China's goal to further improve maternal health. Especially the distribution of health workforce and access to antenatal care visits resulting in disparities across provinces should be tackled more efficiently by the Chinese government. But concerning the urban-rural-divide the government has done a good job as in most factors' disparities have practically vanished.
Of, course the system which protect prenatal maternal health in Russia has many improvements and positive influences. First, the maternal mortality rate has a strong tendency to decrease, in 2012 by 27.2% from 44.2% in 1999 to 31.9% in 2003 per 100 thousand live births (Russian Federal State Statistics Service, 2012). Second, approved scheme of dynamic monitoring of pregnant and women, gynecological patients, the recommended structure, equipment list and equipment of centers for infertility treatment, etc. Аnd the same time the proportion of persons receiving social assistance among those who are not poor on the basis of current income is even higher than the proportion of recipients among the poor. Also still there is a big issue of demographic crisis and high level of abortions. According to Russian statistics, a large number of abortions leads to high mortality of women. In addition, the exclusion of family life from the intervention of public institutions very often leads to negative consequences. In this regard, the state should take measures not only at the medical level, but also social.
Looking into all countries, all had a significant decrease in the mortality rates, but researchers and health specialists, especially from the WHO, credit such result not only to the healthcare policy, but also to multisectoral changes, such as labor rights and educational level. Besides, in terms of data gathering the three countries lack of local surveys, therefore it would be relevant for all countries to disseminate population-based surveys, in all of its regions, especially for the remote areas. Lastly, within the BRICS framework, these countries could work together to exchange their best practices and specialized knowledge regarding maternal health policy.