Maternal and child health in Yushu, Qinghai Province, China

Introduction. Surmang, Qinghai Province is a rural nomadic Tibetan region in western China recently devastated by the 2010 Yushu earthquake; little information is available on access and coverage of maternal and child health services. Methods. A cross-sectional household survey was conducted in August 2004. 402 women of reproductive age (15-50) were interviewed regarding their pregnancy history, access to and utilization of health care, and infant and child health care practices. Results: Women’s access to education was low at 15% for any formal schooling; adult female literacy was <20%. One third of women received any antenatal care during their last pregnancy. Institutional delivery and skilled birth attendance were <1%, and there were no reported cesarean deliveries. Birth was commonly attended by a female relative, and 8% of women delivered alone. Use of unsterilized instrument to cut the umbilical cord was nearly universal (94%), while coverage for tetanus toxoid immunization was only 14%. Traditional Tibetan healers were frequently sought for problems during pregnancy (70%), the postpartum period (87%), and for childhood illnesses (74%). Western medicine (61%) was preferred over Tibetan medicine (9%) for preventive antenatal care. The average time to reach a health facility was 4.3 hours. Postpartum infectious morbidity appeared to be high, but only 3% of women with postpartum problems received western medical care. 64% of recently pregnant women reported that they were very worried about dying in childbirth. The community reported 3 maternal deaths and 103 live births in the 19 months prior to the survey. Conclusions: While China is on track to achieve national Millennium Development Goal targets for maternal and child health, women and children in Surmang suffer from substantial health inequities in access to antenatal, skilled birth and postpartum care. Institutional delivery, skilled attendance and cesarean delivery are virtually inaccessible, and consequently maternal and infant morbidity and mortality are likely high. Urgent action is needed to improve access to maternal, neonatal and child health care in these marginalized populations. The reconstruction after the recent earthquake provides a unique opportunity to link this population with the health system. © 2011Wellhoner et al; licensee BioMed Central Ltd. In August 2004 the Surmang Foundation collaborated with the Yushu County Department of Maternal and Child Health to conduct household surveys of reproductive age women (15-50 years) among the sparse nomadic population residing in Surmang Clinic's surrounding catchment area. The population and distribution of inhabitants in the region were initially identified and enumerated in two mapping exercises of surrounding villages and nomadic areas in consultation with village and community leaders (June-July 2004). The survey tool was adapted initially from the Nepal Reproductive Health Survey [8] and another similar regional survey [9]. The instrument was refined for contextual appropriateness and additional content added based on several informal focus group discussions with local women (n = 5-10/group) regarding pregnancy, childbirth and infant health. Three villages were chosen for focus groups, all in close proximity to the Surmang Clinic, and all with less than 12 women currently residing in the village. Women present in the villages on the day of the focus groups were asked to participate, and a total of 22 women agreed. All 22 women interviewed were farmers. Participation was on a voluntary basis, and only one woman of those approached declined to participate. Those villages used for focus groups were excluded from the subsequent survey sample. The focus group script was created in English and translated to Tibetan. One of the 22 women was interviewed separately as a key informant in creating the focus group script. Two female project staff conducted the groups; one fluent in Chinese and local Tibetan dialect and another fluent in Chinese, local Tibetan and English. While the first woman led the focus groups in Kham Tibetan, the second took notes in Chinese, which were then translated by her into English for analysis. The focus group script included open-ended questions regarding normal self-care during pregnancy and birth as well as recognition and management of complications. There were also questions regarding common causes of childhood illness, their management and overall care seeking behavior for pregnancy, birth, babies and children. Prompts for the focus group leader where included to help elicit relevant information. The survey itself was primarily a closed-ended questionnaire containing sections on socio-demographic information, marital and reproductive history, current and prior pregnancy histories, prior delivery history, postpartum history, infant care and health at birth, breastfeeding and complementary foods, child health, access to health facilities and maternal mortality. Since this was a self-reported retrospective survey of women with very little access to health care, no medical verification of their self-reported symptoms, problems or complications was available. Most of the questions regarding symptoms and problems included a short list of possible problems, and the woman was asked to respond yes or no to each item in the list. Which of the following problems did you have during your last pregnancy? Did you have... (read aloud) 1. Vaginal bleeding? Yes No DK NR 2. Swelling in face, hands and feet (ALL 3)? Yes No DK NR 3. Fever? Yes No DK NR 4. Headache? Yes No DK NR 5. Dizziness and blurry vision (BOTH)? Yes No DK NR 6. Abdominal Pain? Yes No DK NR Did you have any of the following problems within one to two months (42 days) of your last child's birth... (read all responses aloud) 1. Excessive vaginal bleeding ? Yes No DK NR 2. Fever? Yes No DK NR 3. Foul smelling vaginal discharge? Yes No DK NR 4. Severe pain in the lower abdomen? Yes No DK NR 5. Burning when you urinate? Yes No DK NR 6. Painful red infected area in breast? Yes No DK NR 7. Feelings of depression? Yes No DK NR The survey included the taking of a complete pregnancy history from each woman, including year of delivery for each pregnancy, her age at delivery, pregnancy outcome (such as live birth, still birth, spontaneous or induced abortion), gestational age, gender, location of delivery and attendant, current age and status of the child and cause of death. Questions were originally written in English, translated to Tibetan, and back translated to English for verification purposes. The survey tool was tested with 10 Kham women in surrounding communities. During the pilot phase, the women were asked about their understanding of the specific questions, and wording of unclear terminology or phrasing was improved. Though efforts were made to use simple local terminology, pretest on community women and check content with back translation, the very low level of education seen amongst the women may have affected their ability to understand and answer questions. Answers to questions regarding subjective complaints during pregnancy and childbirth were also subject to recall bias. The survey required approximately 30 minutes to complete. Interviews were conducted by eight Kham women who were literate and fluent in the local Kham dialect. Two Tibetan clinic physicians trained the interviewers over a 2-day period, reviewing individual question content and responses, survey skip patterns, data entry, and communication techniques. Each interviewer conducted 4-5 test interviews among fellow trainees before beginning fieldwork. The target sample included all women of reproductive age within accessible regions of the clinic catchment area. Accessible areas were selected based on travel time within 6 hours from the Surmang Clinic by vehicle, horseback or on foot. Given the nomadic lifestyle and the rigorous Himalayan terrain, challenges arose in mapping and enumerating all potential inhabitants in the region; however, extensive efforts were made to include women in difficult to access areas, such as inhabitants of cave-dwellings and pastoralists in high pasture lands. The number of women of reproductive age was enumerated based on the surveyors' interviews with village-family leaders and estimated to be around 600. Oral consent was obtained prior to conducting the interview. Data was entered into an SPSS database, later converted to Stata, then reviewed and cleaned of outlying values. Unique identifiers were eliminated. Continuous data was summarized by mean and standard deviation if normally distributed, otherwise by median and range. Categorical data was summarized by simple frequency tabulation. Approval to conduct the survey was provided by the Yushu Department of Public Health and Maternal and Child Health and the Beijing United Family Hospital Ethics Review Board; the Institutional Review Board of the Johns Hopkins Bloomberg School of Public Health provided approval for data analysis.